Additional Enrollment The below payers require Dental providers to complete additional enrollment paperwork before they may submit their claims electronically. For each payer listed below which you would like to submit electronic claims to please click on the carrier name, download the additional enrollment form(s) and once complete return the form to the fax number or address listed on the instruction sheet. Please ensure all necessary information is accurate and all required signatures are present. If you require assistance completing an enrollment form or have questions please contact Emdeon Dental Provider Enrollment at 888-255-7293 option 1. All enrollment forms are in Adobe Acrobat® format (.pdf). Ifyou do not have Adobe Acrobat® Reader™, you may download it here. |
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ALL DOCUMENTS MUST BE PRINTED WITH 'DOCUMENTS AND MARKUPS' OPTION IN PRINT DIALOG (DEFAULT IS ONLY 'DOCUMENT') TO ENSURE PROPER PRE-FILLING OF FORM DATA |
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
CBAL1 -- Alabama BCBS
CBAL1 -- Alabama BCBS Tax ID Change
CKAL1 -- Alabama Medicaid
CKAL1 -- Alabama Medicaid Tax ID Change
CKAK1 -- Alaska Medicaid
47009, 61305, 72630, 13317, CX068, 36088, 93024, 13411 -- Ameritas NPI Registration
GWD01, 80314, 84102, 47198, 84099, 84103, 84105, 00700, CBGA1, 84101, CB923, CB950 -- Anthem NPI Registration
CKAR1 -- Arkansas Medicaid
61472 -- Blue Cross of North Carolina Federal Employee Claims
CX028 -- Bridgeport LLC NPI Registration
CX095 -- Capitol Dental
CKOH2 -- Caresource
CKCO1 -- Colorado Medicaid
CKCO1 -- Colorado Medicaid EDI Update
77828 -- Companion Life
CPPCH -- Cook Children's Health Plan
CKDE1 -- Delaware Medicaid
94146 -- Denti-Cal / Medicaid of California
CX089 -- Deseret Mutual Benefit Administrators
CKDC1 -- District of Columbia Medicaid
CX052, CKIL1, CKKY3, CKMA1, CKVA1, CX014 -- Doral NPI Registration
CX050 -- First Care / Southwest Life and Health
CX090 -- First Continental Life and Accident Insurance
CKFL1 -- Florida Medicaid
13551 -- GHI - New York (Group Health Inc.)
CKGA1 -- Georgia Medicaid
CBID1 -- Idaho BC
CBID2 -- Idaho BS
CKID1 -- Idaho Medicaid
CX070 -- Indiana Childrens Special Healthcare
CKIN1 -- Indiana Medicaid NPI Registration
CBIA1 -- Iowa Blue Dental - Wellmark
CBIA1 CBIA2
CKIA1 -- Iowa Medicaid
57038 -- Kanawha Insurance Co.
CBKS1 -- Kansas BS
06126 -- Kansas City BCBS of Missouri
CKKS1 -- Kansas Medicaid NPI Registration
CDKY1 -- Kentucky Delta Dental NPI Registration
CKKY1 -- Kentucky Medicaid
CKKY1 -- Kentucky Medicaid 2
93093 -- Lifewise Health Plan of Oregon
23739 -- Louisiana BCBS
CKLA1 -- Louisiana Medicaid
CKLA1 -- Louisiana Medicaid Yearly Certification Statement
CKME1 -- Maine Medicaid
CBMA1 -- Massachusetts BCBS
65978 -- Metlife
CKMI1 -- Michigan Medicaid
CKMN1 -- Minnesota Medicaid
CBMS1 -- Mississippi BCBS
CKMS1 -- Mississippi Medicaid
CKMO1 -- Missouri Medicaid NPI Registration
CBMT1 -- Montana BCBS
CKMT1 -- Montana Medicaid NPI Registration
National Provider Indentifier (NPI)
CKNE1 -- Nebraska Medicaid
CKNV1 -- Nevada Medicaid
CKNH1 -- New Hampshire Medicaid
22099 -- New Jersey BCBS
CKNJ1 -- New Jersey Medicaid
CKNM1 -- New Mexico Medicaid
CBNYE -- New York BCBS - Eastern
CBNYW -- New York BCBS - Western
CKNY1 -- New York Medicaid
CKNY1 -- New York Medicaid TPA
61472 -- North Carolina Health Choice for Children
CKNC1 -- North Carolina Medicaid
CX004 -- North Dakota BCBS
CKND1 -- North Dakota Medicaid NPI Registration
CKOH1 -- Ohio Medicaid
CKOK1 -- Oklahoma Medicaid NPI Registration
CB850 -- Oregon BCBS
CDOR1 -- Oregon Delta Dental NPI Registration
CKOR1 -- Oregon Medicaid
CX080 -- PEHP (Publice Employees Health Program)
CB865 -- Pennsylvania BCBS
CKPA1 -- Pennsylvania Medicaid
93200 -- Regence BS / Regence Northwest Health
CB870 -- Rhode Island BCBS
CKRI1 -- Rhode Island Medicaid
CX030, CX048 -- Safeguard
91184 -- Sanford Health Plan
CX107 -- Select Health
CX038 -- Serentas Dental Care Solutions
38520 -- South Carolina BCBS
CKSC1 -- South Carolina Medicaid
46450 -- State Auto
CBTN1 -- Tennessee BCBS
CB900 -- Texas BCBS
CPPTX -- Texas Childrens Health Insurance (TX CHIPS)
CKTX1 -- Texas Medicaid
25175 -- Three Rivers Healthplan of Monroe PA
CX002 -- United Concordia
CX007
CX013
CBPA2
CB865
66705 -- Unity Health insurance Corp
CBUT1, CBUTF -- Utah BCBS
CKUT1 -- Utah Medicaid
CKWA1 -- Washington Medicaid
CKWV1 -- West Virginia Medicaid
CKWY1 -- Wyoming Medicaid
