If you don't see the form you’re looking for, please refer to the Optum Pro Portal.
EFT Enrollment Forms (currently unavailable, coming soon)
ePayment/EFT allows providers to receive payments electronically from payers that have contracted with Change Healthcare to perform this service.
Real-time enrollment forms
Real-time functions provide the ability to verify eligibility, check claims status, locate providers, review requests and responses and make claim-related financial inquiries.
Each provider must be set up in the system to access real-time functions.
- New customers: Please contact the sales team regarding real-time products.
- Current customers: Please contact your vendor for assistance.
Commonly used real-time enrollment forms
- CHC MID/TID/TPG Creation Form – Initial request for a MID/TID or TPG
- Real-time NPI Payer Add – Existing Clients – Add additional NPIs
Full list of enrollment forms
Association de Maestros Puerto Rico
Blue Cross & Blue Shield of Delaware
California Medi-Cal
Capital Blue Cross
HealthPartners MN
Highmark Blue Cross & Blue Shield of Pennsylvania
First Medical Health Plan (IMC)
Mapfre
Medical Card System (MCS)
Medicare Medex
Michigan Medicaid
MMM Healthcare
MMM Healthcare (Reform)
Mountain State Blue Cross of West Virginia
Nebraska Medicaid
Triple-S Advantage
Triple-S Salud
Utah Medicaid
Vermont Medicaid VT
36215 - CENTRAL STATES HEALTH AND WELFARE FUNDS TEAMCARE - ERA
CKNH1 - NEW HAMPSHIRE MEDICAID
VAICE - DIVISION OF IMMIGRATION HEALTH SERVICES
52133 - United Healthcare Dental
34108 - E.S. BEVERIDGE & ASSOCIATES
71412 - MUTUAL OF OMAHA INSURANCE COMPANY
25849 - EAST BOSTON NEIGHBORHOOD PACE
23223 - THE LOOMIS COMPANY - TPA WYOMISSING, PA (IHS GATEWAY PAYER)
12399 - PHYSICIANS HEALTH PLAN OF NORTHERN INIDIANA (FORT WAYNE, IN)
03036 - EMPLOYEE BENEFITS PLAN ADMINISTRATION, INC. (E.B.P.A.)
39026 - UMR (FORMERLY UMR WAUSAU)
11329 - INTERNATIONAL BENEFITS ADMINISTRATORS
VACCN - VETEREANS AFFAIRS COMMUNITY CARE NETWORK (CCN) REGIONS 1-3
34150 - THE HEALTHPLAN OF WEST VIRGINIA, INC
35198 - Payer UNIFIED GROUP SERVICES
35182 - LUMINARE HEALTH AZ, IL, IN, MD, MN, NC, PA
38221 - REGENCY EMPLOYEE BENEFITS
ECHO - 35112 - EMPLOYEE PLANS, LLC
36347 - NORTHERN ILLINOIS HEALTH PLAN
36373 - PRAIRIE STATES ENTERPRISES, INC
37279 - INSURANCE ADMINISTRATORS OF AMERICA, INC
38225 - LUMINARE HEALTH DETROIT
11752 - CLAIMSBRIDGE HIGH PERFORMANCE NETWORK (HPN)
39081 - BENEFIT PLAN ADMINISTRATORS CO. - EAU CLAIRE, WI
41101 - MIDWEST DENTAL BENEFITS
42137 - TRISTAR BENEFIT ADMINISTRATORS (W. DESMOINES, IA)
44444 - AMERICAN POSTAL WORKERS UNION HEALTH PLAN
51020 - INTEGRA ADMINISTRATIVE GROUP (SEAFORD, DE)
58102 - COVENANT ADMINISTRATORS, INC. (ATLANTA, GA)
61425 - TRUSTMARK SMALL BUSINESS BENEFITS
81264 - NIPPON LIFE INSURANCE COMPANY OF AMERICA
81883 - MUNICIPAL HEALTH BENEFIT FUND
88067 - TALL TREE ADMINISTRATORS
91078 - TRUSTEED PLANS SERVICE CORPORATION
93050 - WILLIAM C EARHART CO., INC
CB404 - PREFERRED HEALTH PLAN OF THE CAROLINAS
04218 - PAN-AMERICAN LIFE INSURANCE COMPANY
CB159 - ADVISORY HEALTH ADMINISTRATORS
LCB01 - LINE CONSTRUCTION BENEFIT FUND
CBAL1 - BLUE CROSS AND BLUE SHIELD OF ALABAMA
11329 - INTERNATIONAL BENEFITS ADMINISTRATORS
CBMA1 - BLUE CROSS BLUE SHIELD OF MASSACHUSETTS
CKNC1 - NCTRACKS (NC MEDICAID DIRECT) - ERA
CKNH1 - NEW HAMPSHIRE MEDICAID – ERA
94267 - HEALTHPARTNERS (MN) – Eligibility
94267 - HEALTHPARTNERS (MN) – ERA
94267 - HEALTHPARTNERS (MN) – CLAIMS
CKME1 - MAINE MEDICAID - Claims
CDCA1 - CALIFORNIA DELTA – TRICARE - ERA
TNCMS - DELTA DENTAL OF TN - ERA
CDMN1 - MINNESOTA DELTA DENTAL DELTA USA - ERA
CDNE1 - NEBRASKA DELTA DENTAL - ERA
56101 - NORTH CAROLINA DELTA DENTAL – ERA
CDIN1 - INDIANA DELTA DENTAL - ERA
85022 - NEW MEXICO DELTA – ERA
R7004 - FLEX COMPENSATION - ERA
CDKY1 - KENTUCKY DELTA DENTAL - ERA
86027 - ARIZONA DELTA DENTAL - ERA
06172 - DART CORPORATION - ERA
SDCMS - DDSD MEDICARE ADVANTAGE - ERA
CDOH1 - OHIO DELTA DENTAL - ERA
CDAR1 - DELTA DENTAL OF ARKANSAS - ERA
CDTN1 - TENNESSEE DELTA DENTAL - ERA
CDND1 - NORTH DAKOTA DELTA DENTAL - ERA
72153 - GROUP BENEFIT ADMINISTRATORS, INC - ERA
CDMI0 - MICHIGAN DELTA DENTAL - ERA
CKNC1 - NCTRACKS (NC MEDICAID DIRECT) – CLAIMS
34192 - MUTUAL HEALTH SERVICES - ERA