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 Sheild of California
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
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
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