Claim Enrollment Forms
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
CPPSA -- Advantage by Superior
CBAL1 -- Alabama BCBS
CBAL1 -- Alabama BCBS Tax ID Change
CKAL1 -- Alabama Medicaid
CKAL1 -- Alabama Medicaid Tax ID Change
CKAK1 -- Alaska Medicaid
CKAR1 -- Arkansas Medicaid
83470 -- Arkansas BC
CKOH2 -- CareSource
CKCO1 -- Colorado Medicaid
CKCO1 -- Colorado Medicaid EDI Update
CPPCH -- Cook Children's Health Plan
CKDE1 -- Delaware Medicaid
94146 -- DentiCal
CX089 -- Deseret Mutual Benefit Administrators
CKDC1 -- District of Columbia Medicaid
CBID1 -- Idaho BC
CBID2 -- Idaho BS
CKID1 -- Idaho Medicaid
CX070 -- Indiana Children's Special Healthcare
CBIA1 -- Iowa Blue Dental - Wellmark
CBIA1 CBIA2 -- FEP Claims only
CKIA1 -- Iowa Medicaid
CBKS1 -- Kansas BS
06126 -- Kansas City BCBS of Missouri
CKKY1 -- Kentucky Medicaid
CKKY1 -- Kentucky Medicaid 2
CKME1 -- Maine Medicaid
CBMA1 -- Massachusetts BCBS
CKMI1 -- Michigan Medicaid
CKMN1 -- Minnesota Medicaid
CBMS1 -- Mississippi BCBS
CKMS1 -- Mississippi Medicaid
National Provider Identifier (NPI)
CKNE1 -- Nebraska Medicaid
CKNV1 -- Nevada Medicaid
CKNH1 -- New Hampshire Medicaid
22099 -- New Jersey BCBS
CKNJ1 -- New Jersey Medicaid
CKNM1 -- New Mexico Medicaid
CBNYE -- New York BCBS Eastern
CBNYW -- New York BCBS Western
CKNY1 -- New York Medicaid
CKNY1 -- New York Medicaid TPA
CX004 -- North Dakota BCBS
CKOH1 -- Ohio Medicaid
CB850 -- Oregon BCBS
CKOR1 -- Oregon Medicaid
CX080 -- Pehp (Public Employees Health Program)
CBPA2 -- Pennsylvania Blue Shield Dental Plus
CKPA1 -- Pennsylvania Medicaid
CB865 -- Pennsylvania BCBS
54771 -- Pennsylvania BC - Highmark
CBTN1 -- Tennessee BCBS
CB900 -- Texas BCBS
CPPTX -- Texas Children's Health Insurance (TX CHIPS)
CKTX1 -- Texas Medicaid
89070 -- United Concordia
CBUT -- Utah BCBS
CBUTF -- Utah BCBS
CKUT1 -- Utah Medicaid
CKWA1 -- Washington Medicaid
CKWV1 -- West Virginia Medicaid
CKWY1 -- Wyoming Medicaid
ERA (EOB) Enrollment Forms
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
CBAL1 -- Alabama Blue Cross
47570 – Alaska Blue Cross Blue Shield (Premera)
CKAK1 – Alaska Medicaid
CKAL1 -- Alabama Medicaid
CKAR1 – Arkansas Medicaid
39065 -- Assurant Health / Time Insurance Company
62308 -- Cigna
87043 -- Coventry Health Care National Network (First Health)
52132 – Cooperative Benefit Administrators (CBA)
34097 – Central Reserve Life
84147 – CHAMPVA/SPINA BIFIDA – VA HAC
CKCO1 – Colorado Medicaid
75136 – CoreSource Little Rock
35182 – CoreSource MD PA IL
35180 – CoreSource NC IN
35183 – CoreSource OH
CKCT1 – Connecticut Medicaid
CKDE1 -- Delaware Medicaid
94146 – Denti-Cal/Medicaid of California
39026 -- Firserv Health - Wausau Benefits / Benesight
CKFL1 – Florida Medicaid
44054 -- Government Employees Hospital Association (GEHA)
80705 -- Great West Healthcare
CKGA1 – Georgia Medicaid
11271 -- Healthplex, Inc.
22099 -- Horizon Healthcare Dental Services
CX010 – CX009 – Health Partners
CBIA1 -- Iowa Blue Cross (FEB Claims Only)
CBID2 -- Idaho Blue Shield
CDIN1 -- Indiana Delta Dental
CKIA1 -- Iowa Medicaid
CKID1 -- Idaho Medicaid
CKIN1 -- Indiana Medicaid
CX070 -- Indiana Children's Special Healthcare
CDIN1 -- Delta Dental of Indiana
CBKS1 -- Kansas Blue Cross
CDKS1 -- Kansas Delta Dental
CKKS1 -- Kansas Medicaid
CKKY1 -- Kentucky Medicaid
23739 -- Louisiana Blue Cross Blue Shield
CKLA1 -- Louisiana Medicaid
CKLA2 -- Louisiana Medicaid
CBMA1 -- Massachusetts Blue Cross
62413 -- Mail Handlers Benefit Plan
CDMI0 -- Michigan Delta Dental
CKMN1 -- Minnesota Medicaid
CKMN1 – Minnesota Medicaid Required Enrollment Form
CBMS1 -- Mississippi BCBS
CKMI1 -- Michigan Medicaid
CKMO1 -- Missouri Medicaid
CKMS1 -- Mississippi Medicaid
CKMT1 -- Montana Medicaid
CDMI0 – Delta Dental of Michigan
CX004 -- North Dakota Blue Cross Blue Shield
81264 -- Nippon Life Insurance Company of America
22099 -- New Jersey Blue Cross-Horizon
CKNC1 -- North Carolina Medicaid
CKNE1 -- Nebraska Medicaid
CKNH1 -- Nebraska Medicaid
CKNV1 -- Nevada Medicaid
CKNY1 -- New York Medicaid
CKNY2 -- New York Medicaid
29076 -- Ohio Medical Mutual
CB833 -- Ohio Medical Mutual
CB850 -- Oregon Blue Cross - Availity
CDOH1 -- Ohio Delta Dental
CKOH1 -- Ohio Medicaid
CKOR1 -- Oregon Medicaid
CDOH1 – Delta Dental of Ohio
93029 -- PacificSource Health Plans
16111 -- POMCO
61271 -- Principal Financial Group
CKPA1 -- Pennsylvania Medicaid
93200 -- Regence Blue Shield - Availity
CB870 -- Rhode Island BCBS
CKRI1 -- Rhode Island Medicaid
RLHA1 -- Renaissance Life & Health
38520 -- South Carolina BCBS
CKSC1 -- South Carolina Medicaid
41143 – Sheffield/Olson/MsQueen
59226 -- The MEGA Life & Health Insurance Company - Insurance Center
CBTN1 -- Tennessee Blue Cross
CKTX1 -- Texas Medicaid
89070 -- United Concordia
25175 -- Unison Health Plan / Three Rivers
CKUT1 -- Utah Medicaid
47570 -- Washington BCBS (Premera)
CKWA1 -- Washington Medicaid
87815 -- Wells Fargo Third Party Administrators, Inc.
39069 -- Wisconsin Delta Dental
CKWI1 -- Wisconsin Medicaid
CKWV1 -- West Virginia Medicaid
CKWY1 -- Wyoming Medicaid
CKDC1 – Washington, D.C. Medicaid
39026 – Wausau Benefits/Fiserv Health/Benesight