Additional Enrollment Emdeon Payer Enrollment is required for the payers listed below. Please follow the steps outlined on the main Enrollment Forms page to ensure a smooth process. 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
Aetna - Step 1 - PSF ERA Provider Setup Form
60054 -- Aetna - Step 2 - Era Enrollment Form 60054
12021_12047_12048_12049 -- Arkansas BCBS Hospital ERA
12M97 -- Cahaba_-_Home_Healthcare_-_States_of_CO,_KS,_MD,_MO,_MT,_ND,_NE,_PA,_VA,_WV,___WY
47198 -- California Blue Cross ERA
94036 -- California Blue Shield ERA
57011 -- California Medicare A ERA
62308 -- Cigna ERA Hospital
12K34 -- Florida Medicaid Hospital ERA
12M34 -- Florida Medicare A ERA
75273 -- Geisinger Health Plan
12M05 -- Georgia Medicare Hospital ERA
12015 -- Gerogia BCBS Hospital ERA
55247 -- HIP Health Plan of New York ERA
06108 -- Health Net of the Northeast
22326 -- Horizon NJ Health
61101 -- Humana ERA
12B08 -- Illinois BCBS ERA
12M08 -- Illinois Medicare A ERA
12M09 -- Indiana Medicare Part A
12K10 -- Iowa Medicaid Hospital ERA
12M10 -- Iowa Medicare Hospital ERA
57324 -- Kansas Medicare Hospital ERA
12M11 -- Kentucky Medicare A Hospital ERA
23284 -- Keystone Mercy Health Plan
12M13 -- Maine Medicare Hospital ERA
22322 -- Maryland Behavioral Health
12B14 -- Massachusetts BCBS ERA
12M16 -- Minnesota Medicare Hospital ERA
12M17 -- Mississippi Medicare Hospital ERA
12M15 -- Missouri Medicare Hospital ERA
12M77 -- Montana Medicare Hospital ERA
31417 -- Nationwide Healthplans
12M19 -- Nebraska Medicare Hospital ERA
12B21 -- New Hampshire BCBS Hospital ERA
12K35 -- New York Medicaid Hospital ERA
12M35 -- New York Medicare Hospital ERA
SX055 -- Passport Advantage_Amerihealth Administrators_Amerihealth HMO of NJ and DE_Amerihealth PPO of NJ and DE_IBC Personal Choice_Keystone East ERA
61129 -- Passport Health Plan
12B60 -- Pennsylvania BCBS
12B81
12M60 -- Pennsylvania Medicare Hospital
12M53 -- Tennessee Medicare A ERA
12B31 -- Texas BCBS Hospital ERA
12M31 -- Texas Medicare A ERA
57106 -- Tricare North Region
12B32 -- Vermont BCBS ERA
12002 -- Virginia Blue Cross Blue Shield Hospital
12004 -- Virginia Medicare Hospital
12M45 -- Washington Medicare Hospital ERA
SB931 -- Washington Regence BCBS ERA
12B29 -- Wisconsin BCBS ERA
12M29 -- Wisconsin Medicare A
