Additional Enrollment The below payers require Dental providers to complete additional enrollment paperwork before they may submit their claims electronically. For each payer listed below which you would like to submit electronic claims to please click on the carrier name, download the additional enrollment form(s) and once complete return the form to the fax number or address listed on the instruction sheet. Please ensure all necessary information is accurate and all required signatures are present. If you require assistance completing an enrollment form or have questions please contact Emdeon Dental Provider Enrollment at 888-255-7293 option 1. 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
CBAL1 -- Alabama BCBS
CBAL1 -- Alabama BCBS Tax ID Change
CKAL1 -- Alabama Medicaid
CKAL1 -- Alabama Medicaid Tax ID Change
CKAK1 -- Alaska Medicaid
CKAR1 -- Arkansas Medicaid
61472 -- Blue Cross of North Carolina Federal Employee Claims
CKCO1 -- Colorado Medicaid
CKCO1 -- Colorado Medicaid EDI Update
77828 -- Companion Life
CKCT1 -- Connecticut Medicaid
CPPCH -- Cook Children's Health Plan
CKDE1 -- Delaware Medicaid
CDCAP -- DeltaCare USA
CX014 -- Doral Dental
CX050 -- FirstCare / SouthWest Life and Health
CKFL1 -- Florida Medicaid
CBID1 -- Idaho BC
CBID2 -- Idaho BS
CKID1 -- Idaho Medicaid
CX070 -- Indiana Childrens Special Healthcare
CKIN1 -- Indiana Medicaid
CBIA1 -- Iowa Blue Dental - Wellmark
CBIA1 CBIA2
CKIA1 -- Iowa Medicaid
CBKS1 -- Kansas BS
06126 -- Kansas City BCBS of Missouri
CKKS1 -- Kansas Medicaid
CKKY1 -- Kentucky Medicaid
CKKY1 -- Kentucky Medicaid 2
23739 -- Louisiana BCBS
CKLA1 -- Louisiana Medicaid
CKLA1 -- Louisiana Medicaid Yearly Certification Statement
CKME1 -- Maine Medicaid
CKMD1 -- Maryland Medicaid
CBMA1 -- Massachusetts BCBS
CKMA1 -- Massachusetts Medicaid
CKMI1 -- Michigan Medicaid
CKMN1 -- Minnesota Medicaid
CBMS1 -- Mississippi BCBS
CKMS1 -- Mississippi Medicaid
CKMO1 -- Missouri Medicaid
CKMT1 -- Montana Medicaid
National Provider Indentifier (NPI)
CBNE1 -- Nebraska BCBS
CKNE1 -- Nebraska Medicaid
CKNV1 -- Nevada Medicaid
CKNH1 -- New Hampshire Medicaid
22099 -- New Jersey BCBS
CKNJ1 -- New Jersey Medicaid
CKNM1 -- New Mexico Medicaid
CKNY1 -- New York Medicaid
CKNY1 -- New York Medicaid TPA
61472 -- North Carolina Health Choice for Children
CKNC1 -- North Carolina Medicaid
CX004 -- North Dakota BCBS
CKOH1 -- Ohio Medicaid
CKOK1 -- Oklahoma Medicaid
CB850 -- Oregon BCBS
CKOR1 -- Oregon Medicaid
93200 -- Regence BS / Regence Northwest Health
CB870 -- Rhode Island BCBS
CKRI1 -- Rhode Island Medicaid
38520 -- South Carolina BCBS
CKSC1 -- South Carolina Medicaid
CBTN1 -- Tennessee BCBS
CB900 -- Texas BCBS
CPPTX -- Texas Childrens Health Insurance (TX CHIPS)
CKTX1 -- Texas Medicaid
25175 -- Three Rivers Healthplan of Monroe PA
CX002 -- United Concordia
CX007
CX013
CBPA2
CB865
95378 -- United Healthcare of River Valley
CKUT1 -- Utah Medicaid
CKVT1 -- Vermont Medicaid
CB923 -- Virginia BCBS
CKVA1 -- Virginia Medicaid
CKWA1 -- Washington Medicaid
CKWV1 -- West Virginia Medicaid
CB950 -- Wisconsin BCBS
CKWI1 -- Wisconsin Medicaid
CKWY1 -- Wyoming Medicaid
