Additional Enrollment The below payers require Dental providers to complete an additional enrollment process before they may receive their Electronic Remittance Advice (ERA). For each payer listed below which you would like to receive ERAs from please click on the carrier name and download the additional enrollment packet. Enrollment varies by payer please follow the instructions as written. 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
60054 -- Aetna
CBAL1 -- Alabama Blue Cross
CKAL1 -- Alabama Medicaid
47570 -- Alaska BCBS (Premera)
CKAK1 -- Alaska Medicaid
CKAR1 -- Arkansas Medicaid
39065 -- Assurant Health / Time Insurance Company
84147 -- CHAMPVA - HAC
94146 -- California Medicaid / Denti-Cal
34097 -- Central Reserve Life
62308 -- Cigna
CKCO1 -- Colorado Medicaid
CKCT1 -- Connecticut Medicaid
52132 -- Cooperative Benefit Administrators (CBA)
75136 -- CoreSource Little Rock
35182 -- CoreSource MD PA IL
35180 -- CoreSource NC IN
35183 -- CoreSource OH
87043 -- Coventry Health Care National Network (First Health)
CKDE1 -- Delaware Medicaid
CKDC1 -- District of Columbia Medicaid
39026 -- Fiserv Health - Wausau Benefits / Benesight
CKFL1 -- Florida Medicaid
CKGA1 -- Georgia Medicaid
44054 -- Government Employees Hospital Association (GEHA)
80705 -- Great West Healthcare
11271 -- Healthplex, Inc.
22099 -- Horizon Healthcare Dental Services
CBID2 -- Idaho Blue Shield - Availity
CKID1 -- Idaho Medicaid
CX070 -- Indiana Children's Special Healthcare
CDIN1 -- Indiana Delta Dental
CKIN1 -- Indiana Medicaid
CBIA1 -- Iowa Blue Cross (FEP Claims Only)
CKIA1 -- Iowa Medicaid
CBKS1 -- Kansas Blue Cross
CDKS1 -- Kansas Delta Dental
CKKS1 -- Kansas Medicaid
CKKY1 -- Kentucky Medicaid
23739 -- Louisiana Blue Cross Blue Shield
CKLA1 CKLA2 -- Louisiana Medicaid
62413 -- Mail Handlers Benefit Plan
CBMA1 -- Massachusetts Blue Cross
CDMI0 -- Michigan Delta Dental
CKMI1 -- Michigan Medicaid
CKMN1 -- Minnesota Medicaid
CBMS1 -- Mississippi BCBS
CKMS1 -- Mississippi Medicaid
CKMO1 -- Missouri Medicaid
CKMT1 -- Montana Medicaid
CBNE1 -- Nebraska Blue Cross
CKNE1 -- Nebraska Medicaid
CKNV1 -- Nevada Medicaid
CKNH1 -- New Hampshire Medicaid
CKNJ1 -- New Jersey Medicaid
CKNY1, CKNY2 -- New York Medicaid
81264 -- Nippon Life Insurance Company of America
CKNC1 -- North Carolina Medicaid
CX004 -- North Dakota Blue Cross Blue Shield
CDOH1 -- Ohio Delta Dental
CKOH1 -- Ohio Medicaid
29076 -- Ohio Medical Mutual
CB833
CKOK1 -- Oklahoma Medicaid
CB850 -- Oregon Blue Cross - Availity
CKOR1 -- Oregon Medicaid
16111 -- POMCO
93029 -- PacificSource Health Plans
CKPA1 -- Pennsylvania Medicaid
61271 -- Principal Financial Group
93200 -- Regence Blue Shield - Availity
RHLA1 -- Renaisance Life & Health
CB870 -- Rhode Island BCBS
CKRI1 -- Rhode Island Medicaid
38520 -- South Carolina BCBS
CKSC1 -- South Carolina Medicaid
CBTN1 -- Tennessee Blue Cross
CKTX1 -- Texas Medicaid
59226 -- The MEGA Life & Health Insurance Company - Insurance Center
25175 -- Unison Health Plan / Tree Rivers
CX002, CX007, CX013, CBPA2, CB865 -- United Concordia
CKUT1 -- Utah Medicaid
47570 -- Washington BCBS (Premera)
CKWA1 -- Washington Medicaid
87815 -- Wells Fargo Third Party Administrators, Inc.
CKWV1 -- West Virginia Medicaid
39069 -- Wisconsin Delta Dental
CKWI1 -- Wisconsin Medicaid
CKWY1 -- Wyoming Medicaid
