Provider Enrollment Forms – Claims and ERA

(Government forms by State Name)

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Payers by Name Government by State	Professional Claims & ERA	Institutional Claims & ERA
AARP United Healthcare (36273)	AARP United Healthcare ERA	see professional form
Aetna (60054)	Aetna ERA Request NEW! 12/03/09	see professional form
Alabama	Alabama BCBS Alabama BCBS – Add Provider to Existing EDI Billing Group Alabama Medicaid Alabama Medicare Part B
Alaska	Alaska BCBS Premera Alaska Medicaid Alaska Medicare Part B
Alohacare (Quest,Medicare)	Alohacare (testing required)
Americhoice (03432, 86047, 86049)	Americhoice ERA Request	see professional form
Arizona	Arizona BCBS Arizona Medicaid (in testing—coming soon) Arizona Medicare Part B
Arkansas	Arkansas BCBS Arkansas Medicaid Arkansas Medicare Part B	Arkansas Medicare Part A
Aultcare (AULTC)	Aultcare **please contact Enroll. Dept. if you are interested in testing for the 835-ERA.
Buckeye Community Health Plan (32004)	Buckeye Community (32004) ERA Request	see professional form
California	California Blue Cross ERA request California Blue Shield ERA request California Medicaid Northern California Medicare Part B Southern California Medicare Part B	California Blue Cross (ERA only—see prof.) California Blue Shield (ERA only—see prof.) California Medicaid Inst.
Carolina Crescent (SX191)	Carolina Crescent (Claims only)
Capario Gateway (Medavant)	Capario Claims Authorization
Caresource Ohio (31114)	Caresource Ohio ERA Request	see professional form
Cigna Healthcare (62308)	Cigna ERA Request (xls)	see professional form
Colorado	Colorado BCBS- Anthem Colorado Medicaid Colorado Medicare Part B Rocky Mountain Health Plan	Colorado BCBS- Anthem Colorado Medicaid Colorado Medicare Part A Rocky Mountain Health Plan
Community Health Network CT (62149) Connecticare (06105)	CHNCT (62149) ERA Request Connecticare (06105) ERA Request	see professional form
Connecticut	Connecticut BCBS- Anthem Connecticut Medicaid Connecticut Medicare Part B	Conn. BCBS- Anthem – Inst.
Delaware	Delaware BCBS Delaware Medicaid Delaware Medicare Part B
District of Columbia (DCMA)	Carefirst BCBS D.C. ERA request DC Medicare Part B
DMERC	DMERC Region A DMERC Region B DMERC Region C DMERC Region D
El Paso First Health Plans (EPF01, EPF03, EPF10, EPF37)	El Paso First Health Plans (Claims only)	El Paso First Health Plans (Claims only)
Fidelis Care New York (11315)	Fidelis Care NY ERA request (xls)
FirstCare (94998, 94999)	FirstCare ERA only	see professional form
Florida	Florida BCBS Florida Medicaid Florida Medicare Part B	Florida BCBS
FQHC – Rural Health Legacy MEDICARE PART A **If provider/clinic is credentialed with a specific state Part A, use the enrollment form for that state.		NGS (UGS) Medicare Legacy (00450) Cahaba GBA Medicare (10301) WPS Medicare Legacy Institutional (52280) (Please email enrollment@practiceinsight.net if you need additional EDI forms.)
Georgia	Georgia BCBS Georgia Medicaid Georgia Medicare Part B	Georgia BCBS Inst. Georgia Medicaid Inst.
Great West (80705)	Great West ERA request (xls)	see professional form
Hawaii	Hawaii BCBS – HMSA Hawaii Medicaid Hawaii Medicare Part B
HealthNet Arizona (38309) HealthNet of the Northeast (06108)	HealthNet Arizona ERA request HealthNet Northeast ERA request
HealthNow New York (55204)	HealthNow New York Claims
Healthpartners MN (HPAMN)	Healthpartners MN Claims & ERA
Humana (61101)	Humana ERA Request	see professional form
Idaho	Idaho Blue Cross Idaho Regence Blue Shield Idaho Medicaid (testing may be required) Idaho Medicare Part B
Illinois	Illinois BCBS ERA request Illinois Medicaid Illinois Medicare Part B	Illinois BCBS ERA request Illinois Medicaid inst. Illinois Medicare Part A
Independent Health NY (95308)	Independent Health (provider testing required)
Indiana	Indiana BCBS-Anthem Indiana Medicaid ERA request Indiana Medicare Part B	Indiana Medicaid ERA request
Iowa	Iowa Blue Cross Blue Shield Iowa Medicaid Iowa Medicare Part B
Kansas	Kansas BCBS Kansas City BCBS Kansas Medicaid Kansas Medicare Part B	Kansas Medicare Part A
Kentucky	Kentucky BCBS-Anthem Kentucky Medicaid Kentucky Medicare Part B
Lifewise Health Plans (91155, 91049)	Lifewise Health Plan Arizona (91155) Lifewise Health Plan Washington (91049)
Louisiana	Louisiana BCBS Louisiana Medicaid Louisiana Medicare Part B	Louisiana BCBS
Maine	Maine Medicare Part B
MAMSI (52148)	MAMSI (52148) ERA Request	see professional form
Managed Health Services – Indiana (39186)	MHS Indiana ERA Request
Maryland	Maryland BCBS Carefirst ERA request Maryland Medicaid Maryland Medicare Part B See also Dist. of Columbia as necessary for Montgomery co. and Prince Georges co.
Massachusetts	Massachusetts BCBS Massachusetts Medicaid Massachusetts Medicare Part B
Medica (94265)	Medica (94265) ERA Request
Michigan	Michigan BCBS Michigan Medicaid Michigan Medicare Part B
Midwest Security (79480)	Midwest Security (79480) ERA Request
Minnesota	Minnesota BCBS Minnesota Medicare Part B Minnesota Medicaid MHCP	Minnesota BCBS
Mississippi	Mississippi BCBS Mississippi Medicare Part B Mississippi Medicaid
Missouri	Missouri BCBS - Anthem Missouri Medicaid Missouri West Western (KC) Medicare Part B Missouri West Eastern Medicare Part B	Missouri Medicaid
Molina Healthcare (multi-state)	Molina Healthcare ERA request
Montana	Montana BCBS Montana Medicaid (in testing) Montana Medicare Part B
Mutual of Omaha (71412)	Mutual of Omaha 71412 ERA request
MVP Health Plan New York (14165)	MVP Health Plan NY (14165) ERA Request
Nebraska	Nebraska BCBS Nebraska Medicaid Nebraska Medicare Part B
Nevada	Nevada BCBS-Anthem Nevada Medicaid Nevada Medicare Part B
New Hampshire	New Hampshire Medicare Part B
New Jersey	New Jersey BCBS New Jersey Medicaid New Jersey Medicare Part B	New Jersey BCBS inst.
New Mexico	New Mexico BCBS ERA request New Mexico Medicaid New Mexico Medicare Part B	New Mexico BCBS ERA request New Mexico Medicare Part A
New York	New York BCBS Rochester - Excellus New York BCBS Utica - Excellus New York BCBS Northeastern New York BCBS Western New York BCBS- Empire New York Medicare Part B- Empire New York Medicare Part B- Queens New York Medicare Part B- Upstate New York Medicaid	New York BCBS- Empire Inst. New York Medicaid Inst.
North Carolina	North Carolina BCBS North Carolina Medicaid North Carolina Medicare Part B
North Dakota	North Dakota BCBS North Dakota Medicare Part B
Ohio	Ohio BCBS - Anthem Ohio Medicaid Ohio Medicare Part B
Oklahoma	Oklahoma BCBS ERA request Oklahoma Medicaid Oklahoma Medicare Part B	Oklahoma BCBS ERA request Oklahoma Medicaid
Oregon	Oregon BCBS Oregon Medicaid Oregon Medicare Part B
Oxford (06111)	Oxford ERA Request
Pacificare (95962, 95964, 95959)	Pacificare (95962, 95964, 95959) ERA Request
Pennsylvania	Pennsylvania Highmark BCBS Pennsylvania Medicaid Pennsylvania Medicare Part B Capital Blue Cross	Blue Cross Northeastern Penn. Penn. Highmark BCBS Central Penn. Highmark BCBS Western Pennsylvania Medicaid
Physicians Hlth Plan of Northern Indiana (12399)	PHPNI (12399) ERA Request
Preferred Care NY Rochester (PCNY0)	Preferred Care NY ERA Request
Railroad Medicare	Railroad Medicare Part B	Railroad Medicare Part A
Rhode Island	Rhode Island BCBS Rhode Island Medicaid Rhode Island Medicare Part B
South Carolina	South Carolina BCBS South Carolina Medicaid South Carolina Medicare Part B
South Dakota	South Dakota BCBS South Dakota Medicaid South Dakota Medicare Part B
Superior Health Plan Texas (39188)	Superior Health Plan TX ERA Request
Tennessee	Tennessee BCBS Tennessee Medicaid Tennessee Medicare Part B	Tennessee BCBS Tennessee Medicaid Tennessee Medicare Part A
Texas	Texas BCBS ERA request Texas Medicaid ERA request Texas Medicare Part B	Texas BCBS ERA request Texas Medicaid ERA request Texas Medicare Part A
Tricare North & South Regions	Tricare Palmetto	Tricare Palmetto
Tricare West Region	Triwest	Triwest
Tricare For Life (TDDIR)	Tricare For Life	Tricare For Life
UCare Minnesota (52629)	UCare Minn. (52629) ERA Request	UCare Minn. (52629) ERA Request
Unicare (80314)	Unicare (80314) ERA Request – please contact PI
Unison (25175)	Unison (25175) ERA Request	Unison (25175) ERA Request
United Healthcare (87726) UHC of River Valley (95378)	United Healthcare (87726) ERA Request UHC of River Valley (95378) ERA Request
UMR – United Medical Resources (31107)	UMR (31107) ERA Request
University Health Plan of New Jersey (22329)	UHP of New Jersey (22329) ERA Request	see professional ERA form
UPMC Health Plan	UPMC Health Plan ERA Request
US Dept of Labor	No clearinghouse access to this payer. Providers should refer to web site: http://owcp.dol.acs-inc.com/portal/main.do
Utah & UHIN	Utah Regence BCBS Utah Medicaid - FFS Utah Medicare Part B Altius Health Plans (SX113) DMBA – Deseret Mutual Benefits Assn (SX105) EMIA – Educators Mutual Insur (SX110) Molina Healthcare Utah (SX109) PEHP – Public Employees Health Prog (SX106) Select Health (SX107)
Value Options	Value Options Commercial (V1001)
Vermont	Vermont Medicare Part B
Virgin Islands	U.S. Virgin Islands Medicare Part B
Virginia	Virginia BCBS Virginia Medicaid Virginia Medicare Part B See also Dist. Of Columbia as necessary for city of Alexandria, Arlington co. and Fairfax co.
Washington	Washington Blue Cross Premera Washington Blue Shield Regence Washington Medicaid Washington Medicare Part B
Washington Labor & Industry (WC001)	Washington L&I (WC001) Claims Only
West Virginia	West Virginia BCBS West Virginia Medicaid ERA only West Virginia Medicare Part B	West Virginia Medicaid Inst. ERA only
Wisconsin	Wisconsin BCBS - Anthem Wisconsin Medicaid Wisconsin Medicare Part B
WPS Private Ins Commercial	WPS Private Ins Comm Plan
Wyoming	Wyoming BCBS Wyoming Medicaid Wyoming Medicare Part B