Medical Billing Clearinghouse - Signature Claims

Signature CLAIMS files

The following files are for use by Signature Claims customers only. For information regarding these files and forms, please contact Signature Claims

PLEASE NOTE how the forms are handled. Some forms MUST be MAILED back to Signature Claims and others can be sent or faxed directly to the insurance company

Latest Payers list	You can right-click on this and save
Signature Claims Business Partner Agreement	This is the agreement to get you started with Signature Claims!!

National

Tri-Care NORTH	Enrollment forms for Tri-Care NORTH. This form they want MAILED directly to Tri-Care North.
Tri-Care SOUTH	Enrollment forms for Tri-Care SOUTH. This form they want MAILED directly to Tri-Care South.
Tri-Care West	Enrollment forms for Tri-care West. These forms can be faxed directed to the Tri-Care administration (WPS).
Tri-Care ERA	Send to WPS to receive ERAs
RailRoad Medicare Enrollment Form	Enrollment forms for Railroad Medicare. You MUST be a Railroad Medicare provider and ALL forms MUST be returned to Signature Claims.
EMDEON Enrollment form	Use this form when using EMDEON for any insurance agencies that issue their own provider numbers.
EMDEON ERA Form	Fill this out and fax or email to Emdeon to receive remittance advice from the commercial payers

Dmerc Jurisdiction States Chart

	For all the below, use the Signature Claims submitter number of V08900526 and use your browser and go to http://www.ngsmedicare.com/NGSMedicare /EDI/EDIEnrollmentAgreement.aspx
Jurisdiction A	Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
Jurisdiction B	Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin
Jurisdiction C	Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia
Jurisdiction D	Alaska, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, Mariana Islands, American Samoa

Arkansas

Arkansas Blue Cross/Blue Shield

This form can be faxed directly to Availity.

Alabama

Alabama Medicare

This form can be mailed or faxed directly to Cahaba

California

Medi-Cal California	This form is for Medi-Cal California. You MUST send this back to Signature Claims AND MUST BE SIGNED IN BLUE INK.
Medicare-Southern California	Enrollment forms for Medicare-Southern California. This requires a signature from the provider.
Medicare-Northern California	Enrollment forms for Medicare-Northern California. This requires a signature from the provider.

Colorado

Colorado Medicare

Enrollment forms for TrailBlazer

Delaware

Medicare-Delaware

Enrollment forms for TrailBlazer (Delaware)

Florida

Medicare Florida	These can be mailed directly to Florida Medicare

Blue Cross/Blue Shield-Florida	Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.

Georgia


Georgia Medicaid	This form must be MAILED to ACS, PO Box 4000, McRae, GA 31055
Georgia Medicare	This form can be mailed or faxed directly to Cahaba

Idaho

Idaho Blue Cross	Fax or mail this form
Idaho Blue Shield	This form can be faxed directly to Availity.
Idaho Medicare Enrollment Form	You need to fill out BOTH of these and send them to Medicare of North Carolina.
Idaho EDI Profile

Illinois

Illinois Medicare	This can be faxed back to WPS
Blue Cross/Blue Shield-Illinois	Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.

Indiana

Indiana Medicare

Fill out the noted on-line form AND the Emdeon form above

Iowa

Iowa Medicare

This can be faxed back to WPS

Kansas

Kansas Blue Cross/Blue Shield	This can be faxed back to ASK-EDI
Kansas Medicare	This can be faxed back to WPS

Kentucky

Kentucky Medicare

Fill out the noted on-line form AND the Emdeon form above

Louisiana

Medicare Information sheet	This provides information for the forms below
Medicare Louisiana Medicare Enroll	Enrollment form for Medicare Louisiana. This can be MAILED or FAXED directly to EDI Services. You will need to include the Signature Claims Payer number of L0868
Medicare Louisiana LOA	Louisiana Medicare Letter of Authorization. This MUST accompany the above form and can be mailed or faxed directly to EDI Services. YOU MUST add the Signature Claims information and include the submitter ID of L0868 for Louisiana.
Medicare Louisiana Medicare ERA	Louisiana Medicare Electronic Remittance form. can be mailed or faxed directly to EDI Services. YOU MUST add the Signature Claims information and include the submitter ID of L0868 for Louisiana

Maine

Maine Medicare Billing Agreement	This form needs to be signed and mailed back to NHIC.

Massachusetts

Massachusetts Medicare Billing Agreement	This form needs to be signed and mailed back to NHIC.

Blue Cross/Blue Shield of MA	EMDEON form that can be faxed back
MASS. BC/BS ERA form	Mass Electronic Remittance form. This must be MAILED in.

Maryland

Medicare-Maryland

Enrollment forms for TrailBlazer (Maryland Medicare)

Michigan

Michigan Blue Cross/Blue Shield	Providers must complete a Provider Trading Partner Agreement online (http://www.bcbsm.com/ ) and enter their provider codes (and NPI) in Provider Authorization Table with c0iib as the submitter and receiver. The provider must call 800.542.0945, option 1 to get their login id and password.
Michigan Medicare	These can be faxed back to WPS

Minnesota

Minnesota Medicaid	This can be faxed or mailed to Minnesota DHS
Minnesota Medicare	These can be faxed back to WPS

Mississippi

Mississippi Medicare	This form can be faxed or mailed directly to Cahaba
Mississippi Blue Cross/Blue Shield	This form needs to be faxed back to SIGNATURE CLAIMS for processing.
Mississippi State Health Plan	This form needs to be faxed back to SIGNATURE CLAIMS for processing.

Missouri

Missouri Medicaid	Email provider information to Signature Claims and Signature Claims will notify Missouri Medicaid
Missouri Medicare	These can be faxed back to WPS

Nebraska

Nebraska Medicare

This can be faxed back to WPS

New Hampshire

New Hampshire Medicare Billing Agreement	This form needs to be signed and mailed back to NHIC.

New Jersey

Medicare-New Jersey	This can be mailed or faxed to (717) 302-4252
Blue Cross/Blue Shield-New Jersey	EMDEON form that can be faxed back to Signature Claims

New Mexico

Blue Cross/Blue Shield-New Mexico

Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.

New York

New York Medicare	Fill out the noted on-line form AND the Emdeon form above (included)
Blue Cross/Blue Shield New York	This can be faxed directly to ASK-EDI

North Carolina

Blue Cross/Blue Shield-North Carolina	Fill this out and fax back to BC/BS of North Carolina
North Carolina Medicare Enrollment Form	You need to fill out BOTH of these and send them to Medicare of North Carolina.
North Carolina EDI Profile

Oklahoma

Blue Cross/Blue Shield-Oklahoma

Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.

Oregon

Oregon Medicare

Follow Instructions to fill out an on-line form

Pennsylvania

Pennsylvania Medicare	These need to be mailed to Highmark
Blue Cross/Blue Shield of Central Pennsylvania	Mail this form directly to Capital Blue Cross

South Carolina

South Carolina Medicaid

Mail this form directly to South Carolina Medicaid AND email your Medicaid information to Signature Claims because of a separate form that must come from the clearinghouse.

Tennessee

Tennessee Medicare Enrollment Form	You need to fill out BOTH of these and send them to Medicare of North Carolina.
Tennessee EDI Profile

Texas

Blue Cross/Blue Shield-Texas	Enrollment form for Availity-Blue Cross/Blue Shield. This form can be faxed directly to Availity.
Medicare-Texas	Enrollment forms for TrailBlazer (Texas Medicare)

UTAH

Utah Medicare

Follow Instructions to fill out an on-line form

Vermont

NHIC/VERMONT Medicare	This form needs to be signed and mailed back to NHIC.

Vermont Medicaid	Enrollment form for Vermont Medicaid that must be MAILED into them.

Virginia

MediCaid-Virginia	These can be faxed in
Medicare-Virginia	Enrollment forms for TrailBlazer (Virginia)

Washington DC

Medicare-Wash D.C.

Enrollment forms for TrailBlazer (Washington DC-Medicare)

Wisconsin

Wisconsin Medicare

These can be faxed back to WPS