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
SB510 -- Alabama BCBS Medical
SKAL0 -- Alabama Medicaid
SMAL0 -- Alabama Medicare Medical
SB930 -- Alaska BCBS Medical
SKAK0 -- Alaska Medicaid Medical
SMAK0 -- Alaska Medicare
SB530 -- Arizona Blue Cross Blue Shield
86062 -- Arizona Foundation for Medical Care
SKAZ0 -- Arizona Medicaid
SMAZ0 -- Arizona Medicare
SB520 -- Arkansas BCBS Medical
SKAR0 -- Arkansas Medicaid
SMAR0 -- Arkansas Medicare Medical
SX145 -- Banner Health AZ
SX067 -- BrickStreet Mutual Insurance aka West Virginia Workman's Comp
47198 -- California Blue Cross
94036 -- California Blue Shield
SKCA0 -- California Medicaid
SMCA1 -- California Medicare (Northern)
SMCA2 -- California Medicare (Southern)
SX191 -- Carolina Crescent Medical
09823 -- Cimarron Medical
SB550 -- Colorado BCBS
SKCO0 -- Colorado Medicaid
SMCO0 -- Colorado Medicare
SB560 -- Connecticut BCBS
SKCT0 -- Connecticut Medicaid
SMCT0 -- Connecticut Medicare
SB580 -- DC BCBS Carefirst
SKDC0 -- DC Medicaid
SMDC0 -- DC Medicare
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
SMDE0 -- Delaware Medicare
SX105 -- Deseret Mutual
SB590 -- Florida BCBS
SKFL0 -- Florida Medicaid
SMFL0 -- Florida Medicare
SB942 -- Freedom Blue Medicare Advantage
75273 -- Geisinger Health Plan
SB600 -- Georgia BCBS
SKGA0 -- Georgia Medicaid
SMGA0 -- Georgia Medicare
SB971 -- Hawaii BCBS
SKHI0 -- Hawaii Medicaid
SMHI0 -- Hawaii Medicare
SX009 -- Health Partners Minnesota
55204 -- Healthnow Division
SX107 -- IHC Intermountain Health Care
SB612 -- Idaho BCBS
SKID0 -- Idaho Medicaid
SMID0 -- Idaho Medicare
SB621 -- Illinois BCBS
SKIL0 -- Illinois Medicaid
SMIL0 -- Illinois Medicare
SX073 -- Independent Health
SB630 -- Indiana BCBS
SKIN0 -- Indiana Medicaid
SMIN0 -- Indiana Medicare
SB640 -- Iowa BCBS
SKIA0 -- Iowa Medicaid
SMIA0 -- Iowa Medicare
SB650 -- Kansas Blue Shield
SB740 -- Kansas City Blue Shield
SMKC0 -- Kansas City Medicare
SKKS0 -- Kansas Medicaid
SMKS0 -- Kansas Medicare
SB660 -- Kentucky BCBS
SKKY0 -- Kentucky Medicaid
SMKY0 -- Kentucky Medicare
SX055 -- Keystone East
91155 -- Lifewise of AZ
23738 -- Louisiana BCBS
SKLA0 -- Louisiana Medicaid
SMLA0 -- Louisiana Medicare
SB680 -- Maine BCBS
SKME0 -- Maine Medicaid
SMME0 -- Maine Medicare
SB690 -- Maryland BCBS Carefirst
SX069 -- Maryland Behavioral Health
SKMD0 -- Maryland Medicaid
SMMD0 -- Maryland Medicare
SB700 -- Massachusetts BCBS
SKMA0 -- Massachusetts Medicaid
SMMA0 -- Massachusetts Medicare
SB710 -- Michigan BCBS
SKMI0 -- Michigan Medicaid Medical
SMMI0 -- Michigan Medicare
SX170 -- Michigan Medicare Plus Blues
SB720 -- Minnesota BCBS
SKMN0 -- Minnesota Medicaid
SMMN0 -- Minnesota Medicare
SB730 -- Mississippi BCBS
SKMS0 -- Mississippi Medicaid
SMMS0 -- Mississippi Medicare
SB741 -- Missouri BCBS (Blue Choice)
SB742
SKMO0 -- Missouri Medicaid
SMMO0 -- Missouri Medicare
SB751 -- Montana BCBS
SKMT0 -- Montana Medicaid
SMMT0 -- Montana Medicare
52280 -- Mutual of Omaha Medicare Nebraska
SB760 -- Nebraska BCBS
SMNE0 -- Nebraska Medicare
SKNE0 -- Nebrasks Medicaid
SB765 -- Nevada BCBS
SKNV0 -- Nevada Medicaid
SMNV0 -- Nevada Medicare
SB770 -- New Hampshire BCBS
SKNH0 -- New Hampshire Medicaid
SMNH0 -- New Hampshire Medicare
22099 -- New Jersey BCBS
SKNJ0 -- New Jersey Medicaid
SMNJ0 -- New Jersey Medicare
SB790 -- New Mexico BCBS
SKNM0 -- New Mexico Medicaid
SMNM0 -- New Mexico Medicare
SB805 -- New York BCBS Central
SB803 -- New York BCBS Empire
SB800 -- New York BCBS Northeastern
SB804 -- New York BCBS Rochester
SB801 -- New York BCBS Western
SKNY0 -- New York Medicaid
SMNY0 -- New York Medicare
SMNY2 -- New York Medicare GHI
SMNY1 -- New York Medicare Western
SX089 -- New York Rochester Preferred Care
SB806 -- New York Utica
SB810 -- North Carolina BCBS
SKNC0 -- North Carolina Medicaid
SMNC0 -- North Carolina Medicare
SB820 -- North Dakota BCBS
SMND0 -- North Dakota Medicare Medical
SB338 -- Ohio Blue Cross Blue Shield
SKOH0 -- Ohio Medicaid
29076 -- Ohio Medical Mutual
SMOH0 -- Ohio Medicare
SB840 -- Oklahoma BCBS
SKOK0 -- Oklahoma Medicaid
SMOK0 -- Oklahoma Medicare
93093 -- Oregon LifeWise Health Plan
SKOR0 -- Oregon Medicaid
SMOR0 -- Oregon Medicare
SB865 -- Pennsylvania BS
SX079
SKPA0 -- Pennsylvania Medicaid
SMPA0 -- Pennsylvania Medicare
09861 -- Pima Health Plan
SX131 -- Providence of Oregon Choice
SX132 -- Providence of Oregon Good Health Plan
SX133 -- Providence of Oregon Health Plan
SX134 -- Providence of Oregon Health Plan HMO
SX135 -- Providence of Oregon Medicaid
SX136 -- Providence of Oregon Medicaid Option
SX137 -- Providence of Oregon Medicare Extra
SX138 -- Providence of Oregon Option
SX139 -- Providence of Oregon Traditional Option
SMPR0 -- Puerto Rico Medicare Medical
SRRGA -- Railroad Medicare (All States)
SB870 -- Rhode Island BCBS
SKRI0 -- Rhode Island Medicaid
SMRI0 -- Rhode Island Medicare
SX141 -- Rocky Mtn Health Plans
SB880 -- South Carolina BCBS
SKSC0 -- South Carolina Medicaid
SMSC0 -- South Carolina Medicare
SB889 -- South Dakota BCBS
SKSD0 -- South Dakota Medicaid
SMSD0 -- South Dakota Medicare
77318 -- Sutter Connect
SB890 -- Tennessee BCBS
SKTN2 -- Tennessee Medicaid Medical
SMTN0 -- Tennessee Medicare
SB900 -- Texas BCBS
SKTX0 -- Texas Medicaid
SMTX0 -- Texas Medicare
SX086 -- Univera Healthcare
SX090
SX091
09830 -- University Family Care
07503 -- University Family Care - Healthcare Group
SB910 -- Utah BCBS
SKUT0 -- Utah Medicaid
SMUT0 -- Utah Medicare
SX173 -- Value Options
SB915 -- Vermont BCBS
SKVT0 -- Vermont Medicaid
SMVT0 -- Vermont Medicare
SX192 -- Vestica Healthcare Medical
SMVI0 -- Virgin Islands Medicare Medical
SB923 -- Virginia BCBS
SKVA0 -- Virginia Medicaid
SMVA0 -- Virginia Medicare
54176 -- Virginia Premier Health Plan
SB930 -- Washington BCBS Premera
SB931 -- Washington BS Regence
SX063 -- Washington Dept of Labor & Industries
SKWA0 -- Washington Medicaid
SMWA0 -- Washington Medicare
SB941 -- West Virginia BCBS Mountain State
SKWV0 -- West Virginia Medicaid
SMWV0 -- West Virginia Medicare
SX067 -- West Virginia Workmans Comp
SB950 -- Wisconsin BCBS
SKWI0 -- Wisconsin Medicaid
SMWI0 -- Wisconsin Medicare
SB960 -- Wyoming BCBS
SKWY0 -- Wyoming Medicaid
SMWY0 -- Wyoming Medicare
