Electronic Billing Enrollment

This is a general purpose walkthrough of the steps needed to get setup to bill Maryland Medicaid. It is by no means exhaustive.

Prior to obtaining a submitter ID with the state of Maryland, you will need the following:

• Company Name
• Contact Name
• Address
• Phone Number
• Fax Number
• Contact Email
• NPI (National Provider Identifier) Number (10 digits)
• Maryland Provider Medicaid Number (9 digits)

The first step is to email mdh.HIPAAEDITEST@Maryland.gov and request a submitter ID. In turn, the state will ask you to fill out three forms. They are provided here and highlighted for ease of entry.

5010 Enrollment Form

• Line 2: Enter your company name i.e. Joe's Adult Daycare
• Line 4: Enter your submitter ID (the part that comes after the ZZ in your MMEE login) i.e. MMEE Login - zzhc0123 means you would fill in 'hc0123'.  If you do not have an ID, this is the place to create your desired ID.
• Line 5: Enter your name i.e. John Deere
• Line 6: Enter your business address
• Line 7: Enter your email address
• Line 8: Enter your phone number
• Line 9: Enter your fax number
• Line 13: Same as Line 4
• Line 30: *837 Professional ONLY: Same as Line 4
• Line 40: Same as Line 4
• Line 44: Same as Line 4

Submitter Identification Form

The purpose of this form is to establish a relationship between the person being paid and the person who is submitting the claims.  For many Medic-Aid clients these two are the same.  You are acting as a billing agent on behalf of yourself as a provider.

• 1
  • New Application - No Previous ID
  • Change of Submitter Agent - Previously Billed With Different Submitter
  • Submitter Identification Form Update - Change of Address, Name, or Update to 835 receiver information
• Electronic Transfer (fax) & Paper Voucher (snail mail)
• 2 a) Enter your company name i.e. Joe's Adult Daycare
• 2 b) Company Address
• 2 c) Maryland Provider Medicaid number (9 digits)
• 2 d) National Provider Identifier (NPI) Number (10 digits)
• 3 a) If you are submitting on behalf of yourself this is the same as 2 a).  If another company is submitting on your behalf then insert their name.
• 3 b) The address of the company listed in 3 a)
• 3 c) The 'ZZ' ID of the company in 3 a).  If you are submitting on behalf of yourself this is the same as line 4 of the 5010 Enrollment Form.  i.e. ZZHC0123
• 4
  • Check: 837 Health Care Claim Professional
  • Check: 835 Health Care Claim Payment/Advice
    • 835 GS Receiver ID: The same ID from 3 c)
• The provider: [Value of 2 a)] hereby authorizes [Value of 3 a)] ....
• Print, sign and date.
• Email this form to mdh.HIPAAEDITEST@Maryland.gov
• Snail mail to:

                                                SYSTEM LIAISON SERVICES
                                                201 W. PRESTON ST., RM SS-18
                                                BALTIMORE, MD  21201
                                                ATTN:  HIPAA DESK

• Additionally, you may fax this form to 410-333-7118.

Trading Partner Agreement

• Provider Name: [Value of SIF 2 a)] or [Value 5010 Enrollment Line 2]
• Provider Address: [Value of SIF 2 b)] or [Value 5010 Enrollment Line 6]
• City, State & Zip Code: Zip Code of Provider Above
• Submitter Agent Name: [Value of SIF 3 a)]
• Submitter Agent Address: [Value of SIF 3 b)]
• City, State & Zip Code: Zip Code of Submitter
• Provider Name: [Value of SIF 2 a)] or [Value 5010 Enrollment Line 2]
• Provider Number: [Value of SIF 2 c)]
• National Provider Identifier (NPI)#: [Value of SIF 2 d)]
• Sign, Date and Phone.
• Email this form to mdh.HIPAAEDITEST@Maryland.gov
• Snail mail to:

                                                Beverly Niedzwick
                                                201 W. PRESTON ST., RM LL-3
                                                BALTIMORE, MD  21201
                                                ATTN:  HIPAA Billing Agreements