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 ERA form
Absolute Total Care SC (20553)	Absolute Total Care SC (20553) ERA Request	see professional ERA form
Aetna (60054)	Aetna ERA Request	see professional ERA 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 Clms Request
America’s 1ST Choice SC-GA (20553)	America’s 1ST Choice SC-GA ERA Request	see professional ERA form
Americhoice (03432, 86047, and 86049 -UHC of PA, pka Americhoice PA)	Americhoice ERA Request	see professional ERA form
Amerigroup (multi-state)	Amerigroup ERA Request	see professional ERA form
Arizona	Arizona BCBS ERA Request Arizona Medicaid (in testing) Arizona Medicare Part B
Arkansas	Arkansas BCBS Arkansas Medicaid Arkansas Medicare Part B	Arkansas Medicare Part A
Aultcare (AULTC)	AultCare **ERA requires payer testing
Bridgeway Health Solutions AZ (68054)	Bridgeway Arizona (68054) ERA request	see professional ERA form
Buckeye Community Health Plan (32004)	Buckeye Community (32004) ERA Request	see professional ERA 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.
Capital District PHP (CDPHP)	Capital District PHP ERA request
Caresource Ohio (31114)	Caresource Ohio ERA Request	see professional ERA form
CareCentrix (11345)	CareCentrix Claims Request
Celticare Health Plan (68060)	Celticare (68060) ERA Request	see professional ERA form
Cigna Healthcare (62308)	Cigna ERA Request (xls)	see professional ERA form
Colorado	Colorado BCBS- Anthem ERA request Colorado Medicaid Colorado Medicare Part B Rocky Mountain Health Plan	Colorado BCBS- Anthem ERA reqeust 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 (xls)	see professional ERA form
Connecticut	Connecticut BCBS- Anthem ERA request Connecticut Medicaid Connecticut Medicare Part B	Conn. BCBS- Anthem ERA request– 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)	see professional ERA form
Family Health Partners (31472, 43173)	Family Health Partners ERA only	see professional ERA form
Fidelis Care New York (11315)	Fidelis Care NY ERA request (xls)	see professional ERA form
FirstCare (94998, 94999)	FirstCare ERA only	see professional ERA form
Florida	Florida BCBS ERA request Florida Medicaid Florida Medicare Part B	Florida BCBS ERA request
Florida Health Care Plan (59322)	FHCP (59322) ERA only
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.)
Freedom Health Medicare Adv (41212)	Freedom Health Mcr Adv (41212) ERA only	see professional ERA form
Georgia	Georgia BCBS Georgia Medicaid Georgia Medicare Part B	Georgia BCBS Inst. Georgia Medicaid Inst
Golden Rule (37602)	Golden Rule ERA Request	see professional ERA form
Great West (80705)	Great West ERA request (xls)	see professional ERA form
Group Health Cooperative (91051)	Group Health Coop (91051) ERA request	see professional ERA form
Harmony Health Plan of IL-IN	Harmony Health Plan of IL-IN ERA Request
Hawaii	Hawaii BCBS – HMSA Hawaii Medicaid Hawaii Medicare Part B
Healthease Florida (59608)	Healthease Florida (59608) ERA Request
HealthNet Arizona (38309) HealthNet of California (95567) HealthNet of the Northeast (06108)	HealthNet Arizona ERA request HealthNet California ERA request HealthNet Northeast ERA request	see professional ERA forms
HealthNow New York (55204)	HealthNow New York Claims
Healthpartners MN (HPAMN)	Healthpartners MN Claims & ERA
Humana (61101)	Humana ERA Request	see professional ERA form
Humana Military (61125)	Humana Military	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 BCBS-Anthem Inst. 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 BCBS Inst. Kansas City BCBS Inst. Kansas Medicare Part A Kansas Medicaid Inst.
Kentucky	Kentucky BCBS-Anthem Kentucky Medicaid Kentucky Medicare Part B	Kentucky BCBS-Anthem Inst.
Lifewise Health Plan Washington (91049)	Lifewise Health Plan Washington (91049)
Louisiana	Louisiana BCBS Louisiana Medicaid, KidMed LA Louisiana Medicare Part B	Louisiana BCBS
Maine	Maine BCBS-Anthem ERA request Maine Medicare Part B
MAMSI (52148)	MAMSI (52148) ERA Request	see professional ERA form
Managed Health Services – Indiana (39186)	MHS Indiana (39186) 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
Metropolitan Health Plan (MHP) (52627)	MHP (52627) ERA Request
Michigan	Michigan BCBS Michigan Medicaid Michigan Medicare Part B
Midwest Security (79480)	Midwest Security ERA Request
Minnesota	Minnesota BCBS ERA request Minnesota Medicare Part B Minnesota Medicaid MHCP	BCBS - see professional form
Mississippi	Mississippi BCBS Mississippi Medicare Part B Mississippi Medicaid
Missouri	Missouri BCBS - Anthem Missouri Medicaid ERA request Missouri Medicare Part B	Missouri BCBS – Anthem Inst. Missouri Medicaid ERA request
Molina Healthcare (Includes these states: CA, MI, NM, OH, TX, WA)	Molina Healthcare ERA request
Montana	Montana BCBS Montana Medicaid ERA request Montana Medicare Part B
Mutual of Omaha (71412)	Mutual of Omaha (71412) ERA Request	see professional ERA form
MVP Health Plan New York (14165)	MVP Health Plan NY (14165) ERA Request
Nebraska	Nebraska BCBS Nebraska Medicaid Nebraska Medicare Part B	Nebraska Medicaid
Nevada	Nevada BCBS-Anthem ERA request Nevada Medicaid Nevada Medicare Part B
New Hampshire	New Hampshire BCBS-Anthem New Hampshire Medicaid New Hampshire Medicare Part B	New Hampshire Medicare Part A
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- ERA request New York Medicare Part B- Downstate, pka 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 Blue Medicare (56152) North Carolina Medicaid North Carolina Medicare Part B	North Carolina Medicare Part A
North Dakota	North Dakota BCBS North Dakota Medicare Part B
Ohio	Ohio BCBS - Anthem Ohio Medicaid Ohio Medicare Part B	Ohio BCBS – Anthem Inst.
Oklahoma	Oklahoma BCBS ERA request Oklahoma Medicaid Oklahoma Medicare Part B	Oklahoma BCBS ERA request Oklahoma Medicaid Oklahoma Medicare Part A
Oregon	Oregon BCBS ERA request Oregon Medicaid Oregon Medicare Part B
Oxford (06111)	Oxford ERA Request (xls)
Pacificare (95962, 95964, 95959)	Pacificare (95962, 95964, 95959) ERA Request
Paramount Health Care (PARHC)	Paramount Health Care ERA Request
Partnership Health Plan (PHP02)	Partnership Health Plan Clms Request
Payspan Health	Payspan Multipayer ERA request
Pennsylvania	Pennsylvania Highmark BCBS Pennsylvania Medicaid Pennsylvania Medicare Part B Capital Blue Cross	Penn. Highmark BCBS (Central and West.) Inst. Pennsylvania Medicaid
Peachstate Georgia (77084)	Peachstate Health Plan (77084) ERA request
Physicians Hlth Plan of Northern Indiana (12399)	PHPNI (12399) ERA Request
Preferred Care NY Rochester (PCNY0)	Preferred Care NY ERA Request
PreferredOne (41147)	PeferredOne ERA Request
Priority Health (38217)	Priority Health ERA Request (.xls)
Principal Life Insurance (61271)	Principal Life (61271) ERA request
Qualchoice Arkansas (35174)	Qualchoice Arkansas 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
Sunshine State Health Plan (68057)	Sunshine State Health Plan (68057) ERA Request	see professional ERA form
Superior Health Plan Texas (39188)	Superior Health Plan TX ERA Request
Tennessee	Tennessee BCBS Tennessee Medicaid Tennessee Medicare Part B	Tennessee BCBS inst Tennessee Medicaid inst 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 and South (38520)	Tricare North Tricare South	Tricare North Tricare South
Tricare –West Region (WESTR)	Triwest	Triwest
Tufts Health Plan (04298)	Tufts Health Plan (04298) claims only
Tricare For Life (TDDIR)	Tricare For Life	Tricare For Life
UCare Minnesota (52629)	UCare Minn. (52629) ERA Request	see professional ERA form
Unison (25175)	Unison (25175) ERA Request	see professional ERA form
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
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) University of Utah Health Plans (SX155)
Value Options	Value Options Commercial claims (V1001) Value Options Mass Behav. Hlth claims (V1003) Value Options ERA Request
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. Virginia Premier Health Plan Inc (VPN01)
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	N/A
Wellcare Health Plans (14163)	Wellcare Multi-State (14163) ERA Request
West Virginia	West Virginia BCBS WV-Freedom Blue Medicare Advantage 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 Commercial (00235)	WPS Commercial (00235)
Wyoming	Wyoming BCBS Wyoming Medicaid Wyoming Medicare Part B