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 ERA
SB510 -- Alabama BCBS Medical ERA
SKAL0 -- Alabama Medicaid ERA
SMAL0 -- Alabama Medicare ERA
SKAK0 -- Alaska Medicaid
SMAK0 -- Alaska Medicare
SB930 -- Alaska Permera BCBS
SB530 -- Arizona BCBS
SMAZ0 -- Arizona Medicare B
SB520 -- Arkansas BCBS
SKAR0 -- Arkansas Medicaid ERA
SMAR0 -- Arkansas Medicare ERA
47198 -- California Blue Cross
94036 -- California Blue Shield
SKCA0 -- California Medicaid
SMCA1 -- California Medicare Northern
SMCA2 -- California Medicare Southern
SX065 -- Capital District PHP ERA
62073 -- Cariten Health ERA
62072 -- Cariten Senior Health
62308 -- Cigna
SB550 -- Colorado BCBS
SMCO0 -- Colorado Medicare
SKCT0 -- Connecticut Medicaid ERA
SMCT0 -- Connecticut Medicare B
SMDC0 -- DC Medicare B
SDMEA -- DME Region A Medical
SDMEB -- DME Region B Medical
SDMEC -- DME Region C Medical
SDMED -- DME Region D Medical
SB570 -- Delaware BCBS
SKDE0 -- Delaware Medicaid
SX105 -- Desert Mutual
SB590 -- FLorida BCBS
23241 -- First Priority Health Plan
SKFL0 -- Florida Medicaid
SMFL0 -- Florida Medicare
SB942 -- Freedom Blue Medicare
75273 -- Geisinger Health Plan
SB600 -- Georgia BCBS
SB601
SKGA0 -- Georgia Medicaid
SMGA0 -- Georgia Medicare
55247 -- HIP Health Plan of New York ERA
SB971 -- Hawaii BCBS
SMHI0 -- Hawaii Medicare
80141 -- Healthfirst ERA
38309 -- Healthnet Arizona
95567 -- Healthnet of CA and OR
06108 -- Healthnet of the Northeast
61101 -- Humana
SB612 -- Idaho BCBS ERA
SKID0 -- Idaho Medicaid
SMID0 -- Idaho Medicare Medical ERA
SB621 -- Illinois BCBS
SMIL0 -- Illinois Medicare
SX073 -- Independent Health
SB630 -- Indiana BCBS
39186 -- Indiana MHS
SKIN0 -- Indiana Medicaid
SMIN0 -- Indiana Medicare B
SB640 -- Iowa BCBS ERA
SKIA0 -- Iowa Medicaid
SMIA0 -- Iowa Medicare Medical ERA
91617 -- Kaiser Permanente of Colorado
34092 -- Kaiser Permanente of Ohio
SB650 -- Kansas BCBS
SB740 -- Kansas City BCBS
SMKC0 -- Kansas City Medicare
SKKS0 -- Kansas Medicaid Medical ERA
SMKS0 -- Kansas Medicare Medical ERA
SB660 -- Kentucky BCBS
SKKY0 -- Kentucky Medicaid
SMKY0 -- Kentucky Medicare ERA
23738 -- Louisiana BCBS ERA
SKLA0 -- Louisiana Medicaid
SMLA0 -- Louisiana Medicare
01260 -- Magellan Health Services
SB680 -- Maine BCBS Medical ERA
SMME0 -- Maine Medicare
SKMD0 -- Maryland Medicaid ERA
SMMD0 -- Maryland Medicare
SB700 -- Massachusetts BCBS
SKMA0 -- Massachusetts Medicaid
SMMA0 -- Massachusetts Medicare
SB710 -- Michigan BCBS Medical ERA
SKMI0 -- Michigan Medicaid
SMMI0 -- Michigan Medicare
SB720 -- Minnesota BCBS
SKMN0 -- Minnesota Medicaid ERA
SMMN0 -- Minnesota Medicare ERA
SKMS0 -- Mississippi Medicaid
SMMS0 -- Mississippi Medicare
SB741 -- Missouri BCBS Medical ERA
SKMO0 -- Missouri Medicaid
SMMO0 -- Missouri Medicare ERA
SB751 -- Montana BCBS Medical ERA
SKMT0 -- Montana Medicaid
SMMT0 -- Montana Medicare ERA
SB804 -- NEW YORK BCBS ROCHESTER ERA
SB806 -- NEW YORK UTICA BCBS ERA
SMNY2 -- NY - MEDICARE B QUEENS ERA
SX190 -- National Imaging Associates
31417 -- Nationwide Healthplans
SKNE0 -- Nebraska Medicaid
SMNE0 -- Nebraska Medicare Medical ERA
04293 -- Neighborhood Health Plan of Boston
SB765 -- Nevada BCBS Medical ERA
SKNV0 -- Nevada Medicaid
SMNV0 -- Nevada Medicare
SB770 -- New Hampshire BCBS
SMNH0 -- New Hampshire Medicare
SKNJ0 -- New Jersey Medicaid
SMNJ0 -- New Jersey Medicare
SB790 -- New Mexico BCBS ERA
SMNM0 -- New Mexico Medicare
SB803 -- New York BCBS Empire
SB800 -- New York BCBS Northeastern
SB801 -- New York BCBS Western
SKNY0 -- New York Medicaid
SMNY0 -- New York Medicare ERA
SX089 -- New York Rochester Area Preferred Care
SMNY1 -- New York Upstate/Western Medicare
SB810 -- North Carolina BCBS
SKNC0 -- North Carolina Medicaid
SMNC0 -- North Carolina Medicare
SMND0 -- North Dakota Medicare ERA
SB338 -- Ohio BCBS
SKOH0 -- Ohio Medicaid
SMOH0 -- Ohio Medicare
SB840 -- Oklahoma BCBS
SMOK0 -- Oklahoma Medicare
SKOR0 -- Oregon Medicaid
SMOR0 -- Oregon Medicare ERA
SB850 -- Oregon Regence BCBS
06111 -- Oxford Health ERA EFT
62155 -- PHP TennCare
93029 -- PacificSource
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
68049 -- Peach State
23045 -- Pennsylvania BS
SB865 -- Pennsylvania BS
SX050
SX051
SX052
SX075
SX078
SX079
SX083
SKPA0 -- Pennsylvania Medicaid
SMPA0 -- Pennsylvania Medicare
38217 -- Priority Health
SRRGA -- Railroad Medicare ERA
SB870 -- Rhode Island BCBS
SMRI0 -- Rhode Island Medicare
54154 -- Sentara
76342 -- Sierra Health Plan
SB880 -- South Carolina BCBS
SKSC0 -- South Carolina Medicaid
SMSC0 -- South Carolina Medicare
SB889 -- South Dakota BCBS
SKSD0 -- South Dakota Medicaid ERA
SMSD0 -- South Dakota Medicare
31053 -- State Farm Medical ERA
39188 -- Superior Health
SB890 -- Tennessee BCBS
SMTN0 -- Tennessee Medicare
SB900 -- Texas BCBS
SKTX0 -- Texas Medicaid
SMTX0 -- Texas Medicare and Indian Health Services
SX176 -- TriCare For Life
57106 -- TriCare North
SCWI0 -- TriCare Western Region
80314 -- Unicare
22329 -- University Health Plan
SB910 -- Utah BCBS
SMUT0 -- Utah Medicare
SX106 -- Utah Public Employees Health Plan
SB915 -- Vermont BCBS
SMVT0 -- Vermont Medicare
SB923 -- Virginia Anthem BCBS
SKVA0 -- Virginia Medicaid
SMVA0 -- Virginia Medicare ERA
54176 -- Virginia Premier Health Plan VPHP
SX022 -- WPS
SB931 -- Washington BCBS Regence
SX063 -- Washington Dept of Labor & Industries
SKWA0 -- Washington Medicaid
SMWA0 -- Washington Medicare
39026 -- Wausau Benefits
SMWV0 -- West Virgina Medicare ERA
SKWV0 -- West Virginia Medicaid
SB950 -- Wisconsin BCBS
39187 -- Wisconsin MHS
SMWI0 -- Wisconsin Medicare
SB960 -- Wyoming BCBS
SMWY0 -- Wyoming Medicare
