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
Full list of enrollment forms
Association de Maestros Puerto Rico
Blue Cross & Blue Shield of Delaware
California Medi-Cal
Capital Blue Cross
First Medical Health Plan (IMC)
First Medical Health Plan (REFORM)
HealthPartners MN
Highmark Blue Cross & Blue Shield of Pennsylvania
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.)
BEAM1 - BEAM DENTAL INSURANCE - ERA
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
29076 – MEDICAL MUTUAL OHIO -ERA
SCS17 - SENDERO HEALTH PLANS – ERA
CKND1 - NORTH DAKOTA MEDICAID - ERA
MGDBP - MOONLIGHT GRAHAM - ERA
SDCOM - SCION COMMERCIAL - ERA
GHP22 - GEISINGER SKYGEN - ERA
UPMCD - UPMCD VIA SKYGEN - ERA
TLZ04 - CYPRESS ANCILLARY - ERA
22099 - HORIZON HEALTHCARE DENTAL SERVICES - ERA
MBAAZ - MULTIFLEX DENTAL (MERCHANTS BENEFIT ADMINISTRATORS) - ERA
46278 - CENTENE DENTAL AND VISION (ENVOLVE DENTAL) - ERA
CKNV1 - MEDICAID OF NEVADA - ERA
CKNV1 - MEDICAID OF NEVADA - CLAIMS
SB650 - BLUE CROSS AND BLUE SHIELD OF KANSAS- ERA
SB740 - BLUE CROSS AND BLUE SHIELD OF KANSAS CITY - ERA
TCMAP - TRAVIS COUNTY MAP - ERA
CKNJ1 - NEW JERSEY MEDICAID - ERA
CKNJ1 - NEW JERSEY MEDICAID - CLAIMS
CKDE1 - DELAWARE MEDICAID - ERA
CKKY1 - KENTUCKY MEDICAID - ERA
PRINT - ALL HEALTH PLAN PRINT (PRINT TO PAPER) - CLAIMS
37275 - Missoula County Medical Benefits Plan - ERA
D3551 - GHI Emblem - New York (Group Health Inc.) - ERA
CKMS1 - MISSISSIPPI DIVISION OF MEDICAID - ERA
CKMS1 - MISSISSIPPI DIVISION OF MEDICAID - CLAIMS
CX070 - INDIANA DEPARTMENT OF HEALTH - CHILDREN'S HEALTH – ERA
CX070 - INDIANA DEPARTMENT OF HEALTH - CHILDREN'S HEALTH – CLAIMS