Submitting claims

Use standard Medicare claim formats

• Electronic submitters: ANSI 837
• Billers submitting paper claims for professional services: CMS-1500 (08/05)
• Billers submitting paper claims for services by facilities and institutions: UB-04

Apply Original Medicare coding rules

• Paper claims – use your national provider identifier and federal tax ID as appropriate.
• Electronic submitters – use NPI only.
• Quantify facility services by revenue code categories, or, if reporting HCPCS codes, the number of units equal to the number of times the service or procedure is being reported.
• Use Medicare CPT codes and defined modifiers.
• Bill diagnosis codes to the highest level of specificity.
• Include physician's or supplier's signature. Include date, degrees or credentials. "Signature on file" is not acceptable.
• Use CMS-approved HCPCS code modifiers.

Some services require a Certificate of Medical Necessity, a durable medical equipment information form, a prescription or other documentation with the first-month supply claim, a first-month rental equipment claim, or a claim for a one-time equipment purchase. We will deny claims that require, but do not include, appropriate documentation.

CMS form	Type of form	Service description
CMS-484	CMN	Oxygen
CMS-846	CMN	Pneumatic compression devices
CMS-847	CMN	Osteogenesis stimulators
CMS-848	CMN	Transcutaneous electrical nerve stimulators
CMS-849	CMN	Seat lift mechanisms
CMS-854	CMN	Section C continuation form
CMS-10125	DIF	External infusion pumps
CMS-10126	DIF	Enteral and parenteral nutrition

CMS documentation forms

• To bill electronic claims for HCPCS codes with local carrier jurisdiction, contact your local Blue plan or their EDI administrator for billing instructions.

Michigan providers should include the following information:

Variable	ANSI 837 Format	CMS-1500 (08/05) Claims Format	UB-04 Claims Format
Reserved for local use		Field 19 – Indicate if Part A skilled nursing facility benefits have been exhausted or if reporting a customized prosthetic device.
Signature	Field CLM06 of 2300 Loop – Provider signature on file must equal "Y"	Field 31 – Signature of physician or supplier including degrees or credentials and date ("Signature on file" is not acceptable)	Field 85 – Provider representative signature and date ("Signature on file" is not acceptable)
Facility source of payment	Field SBR09 of 2000B Loop (MA)	N/A	Field 50 – 1st position "C" for Medicare
Professional source of payment	Field SBR09 of 2000B Loop (MB)	N/A	N/A
Facility Payer ID	Field NM109 of 2010BB Loop (00210)	N/A	Field 50 – 2nd thru 6th position (00210)
Professional Payer ID	Field NM109 of 2010BB Loop (00710)	N/A	N/A

Michigan providers billing claims with regional carrier jurisdiction

Complete a provider authorization and register your national provider identifier with us. Use source of payment Medicare B DMERC as the source of payment when completing the provider authorization.

Variable	ANSI 837 format	CMS-1500 (08/05) claims format	UB-04 claims format
Professional Payer ID	Segment NM109 of 2010BB Loop (00710) – Report "MADME" (Payer ID)	N/A	N/A
CMN or other appropriate documentation	Segment SBR09 of 2000B Loop – Report "MB" (Source of pay)

• Remember to send DME/P&O and medical supply claims correctly based on the carrier jurisdiction.
• Submit claims within one calendar year of the date of service or we cannot pay for the service. You cannot charge a patient if you did not submit the claim to us.
• BCBSM or your local Blue plan will send you the remittance advice.
• BCBSM or your local Blue plan will reimburse you.