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
60054 -- Aetna
12B54 -- Alabama BCBS
12B02 -- Arizona BCBS Hospital ERA
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
62308 -- Cigna ERA Hospital
12K34 -- Florida Medicaid Hospital ERA
12M34 -- Florida Medicare A ERA
75273 -- Geisinger Health Plan
12M05 -- Georgia Medicare Hospital ERA
55247 -- HIP Health Plan of New York ERA
06108 -- Health Net of the Northeast
95567 -- Healthnet of CA and OR
12M08 -- Illinois Medicare A ERA
12M09 -- Indiana Medicare Part A
12K10 -- Iowa Medicaid Hospital ERA
12M10 -- Iowa Medicare Hospital ERA
57325 -- Kansas BCBS
57324 -- Kansas Medicare Hospital ERA
12M11 -- Kentucky Medicare A Hospital ERA
01260 -- Magellan
12010 -- Maryland Medicare
12B14 -- Massachusetts BCBS ERA
12M17 -- Mississippi Medicare Hospital ERA
12M15 -- Missouri Medicare Hospital ERA
12B77 -- Montana BC ERA
12M77 -- Montana Medicare Hospital ERA
SX190 -- National Imaging Associates
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
12B23 -- North Carolina BCBS
12K23 -- North Carolina Medicaid
SX055 -- Passport Advantage_Amerihealth Administrators_Amerihealth HMO of NJ and DE_Amerihealth PPO of NJ and DE_IBC Personal Choice_Keystone East ERA
12M60 -- Pennsylvania Medicare Hospital
12M55 -- South Carolina Medicare A + RHHI ERA
SB889 -- South Dakota BCBS
12K36 -- South Dakota Medicaid
12M53 -- Tennessee Medicare A ERA
12B31 -- Texas BCBS Hospital ERA
12K64 -- Texas Medicaid
12M31 -- Texas Medicare and Indian Health Services
12X43 -- TriCare For Life
12C01 -- TriCare Western Region
57106 -- Tricare North Region
80314 -- Unicare ERA
12B42 -- Utah BCBS Hospital ERA
12M84 -- Utah Medicare Hospital ERA
12B32 -- Vermont BCBS ERA
12002 -- Virginia Blue Cross Blue Shield Hospital
12003 -- Virginia Medicaid Hospital ERA
12004 -- Virginia Medicare Hospital
54176 -- Virginia Premier
12X29 -- WPS Commercial
12M45 -- Washington Medicare Hospital ERA
12B28 -- West Virginia BCBS
12B29 -- Wisconsin BCBS ERA
12M29 -- Wisconsin Medicare A
12M30 -- Wyoming Medicare Hospital ERA