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
12B54 -- Alabama Blue Cross Hospital
12M01 -- Alabama Medicare
12B47 -- Alaska BCBS
12K86 -- Alaska Medicaid
12M02 -- Arizona Medicare
12021 -- Arkansas Blue Cross
12022 -- Arkansas Medicare
12M97 -- Cahaba - Home Healthcare (CO, KS, MD, MO, MT, ND, NE, PA, VA, WV, & WY
57016 -- California Medicaid
12M64 -- California Medicare
57011 -- California Medicare Home Health
12K85 -- Carolina Crescent
12K03 -- Colorado Medicaid
12M03 -- Colorado Medicare
12K04_12K79 -- Connecticut Medicaid
12M04 -- Connecticut Medicare
12001 -- DC Medicaid
12M63 -- DC Medicare
12B76 -- Delaware Blue Cross
12K87 -- Delaware Medicaid
12M76 -- Delaware Medicare Hospital
SX105 -- Desert Mutual
12K34 -- Florida Medicaid Hospital
12M34 -- Florida Medicare
75273 -- Geisinger Health Plan
12K05 -- Georgia Medicaid
12M05 -- Georgia Medicare
12B62 -- Hawaii BCBS
12K62 -- Hawaii Medicaid Hospital
12M62 -- Hawaii Medicare
12X51 -- HealthPartners Minnesota Hospital
38216 -- HealthPlus of Michigan
12B07 -- Idaho Blue Cross
12K07 -- Idaho Medicaid
12M07 -- Idaho Medicare
12B84 -- Idaho True Blue
12M08 -- Illinois Medicare
12M09 -- Indiana Medicare
12B10 -- Iowa BCBS
12K10 -- Iowa Medicaid
12M10 -- Iowa Medicare
57325 -- Kansas Blue Cross
12B66 -- Kansas City BCBS
57324 -- Kansas Medicare
12K11 -- Kentucky Medicaid
12M11 -- Kentucky Medicare
12B12 -- Louisiana BCBS
12K12 -- Louisiana Medicaid
12M12 -- Louisiana Medicare
12K13 -- Maine Medicaid
12M13 -- Maine Medicare
22322 -- Maryland Behavioral Health
12007 -- Maryland Medicaid
12010 -- Maryland Medicare
12K14 -- Massachusetts Medicaid
12M14 -- Massachusetts Medicare
52280 -- Med Mutual of Omaha Nebraska
12K37 -- Michigan Medicaid Hospital
12M18 -- Michigan Medicare
12B16 -- Minnesota BCBS
12K16 -- Minnesota Medicaid
12M16 -- Minnesota Medicare
12B17_12B82 -- Mississippi Blue Cross
12K17 -- Mississippi Medicaid
12M17 -- Mississippi Medicare
12M15 -- Missouri Medicare
12B77 -- Montana BCBS Hospital
12M77 -- Montana Medicare
12000 -- National Capital Area BCBS - Carefirst
12B19 -- Nebraska Blue Shield
12K19 -- Nebraska Medicaid
12M19 -- Nebraska Medicare Hospital
12K20 -- Nevada Medicaid
12M20 -- Nevada Medicare
12K90 -- New Hampshire Medicaid
12M21 -- New Hampshire Medicare
22099 -- New Jersey BCBS
12006 -- New Jersey Medicaid
12005 -- New Jersey Medicare
12M22 -- New Mexico Medicare
12B35 -- New York BC Empire State
12B40 -- New York BC of Rochester
12B38 -- New York BC of Utica - Watertown
12B39 -- New York BC of Western New York
12B37 -- New York BCBS Central
12B71
12B68 -- New York BCBS Northeastern
12B36 -- New York City BC (Empire Omnipro)
12M35 -- New York Medicare
12K35 -- New York State Medicaid
12B23 -- North Carolina Blue Cross
12K23 -- North Carolina Medicaid
12M23 -- North Carolina Medicare
12B78 -- North Dakota BC (Noridian)
12M82 -- North Dakota Medicare Hospital
12M24 -- Ohio Medicare
12M37 -- Oklahoma Medicare Hospital
12K41 -- Oregon Medicaid
12M41 -- Oregon Medicare
12M81 -- Partnership Health of California-CAPHP
12B81 -- Pennsylvania BCBS Central Highmark
12M60 -- Pennsylvania Medicare Hospital
12B60 -- Pennsylvania Western BC
12M80 -- Regional Home Health & Hospice ( AL, FL, MS, IL, IN & OH)
12B74 -- Rhode Island BCBS
12K74 -- Rhode Island Medicaid
84065 -- Rocky Mtn Health Plans
12B55 -- South Carolina BCBS
12K55 -- South Carolina Medicaid
12M55 -- South Carolina Medicare (SW Region RHHI- FL, GA, KY, NC, SC &TN) (SE Region RHHI- AR, LA, NM, OK &TX)
12B33 -- South Dakota BCBS
12K36 -- South Dakota Medicaid Hospital
12M83 -- South Dakota Medicare Hospital
12B45_12B53 -- Tennessee BC
12K46 -- Tennessee Medicaid
12M53 -- Tennessee Medicare
12M31 -- Texas Medicare and Indian Health Services
12X43 -- TriCare For Life
57106 -- TriCare North
12C01 -- TriCare Western Region
12X17 -- Univera Healthcare
12X19
12X20
12B42 -- Utah BCBS Hospital
12M84 -- Utah Medicare Hospital
43307 -- ValueOptions/MBHP (MA Behavioral Health Partnership)
12B32 -- Vermont BCBS
12K26 -- Vermont Medicaid Hospital
12002 -- Virginia BCBS
12004 -- Virginia Medicare
12K83 -- Virginia Premier
12X29 -- WPS Commercial
12B27 -- Washington BCBS Premera
12K27 -- Washington Medicaid Hospital
12M45 -- Washington Medicare Hospital
12B28 -- West Virginia Blue Cross
12K28 -- West Virginia Medicaid
12M29 -- Wisconsin Medicare Part A and ALL States FQHC sites except AZ, MT, ND, SD, UT & WY
12B30 -- Wyoming BC
12K30 -- Wyoming Medicaid
12M30 -- Wyoming Medicare
