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Enrollment forms

Optum has developed processes to allow payers and providers to electronically exchange sensitive information. Find forms for medical claims, patient eligibility, ERA, and EFT payment information.

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.

  1. New customers: Please contact the sales team regarding real-time products.
  2. Current customers: Please contact your vendor for assistance.

Commonly used real-time enrollment forms

Full list of enrollment forms

Auxilio Plan de Socios
Auxilio Salud Plus
Association de Maestros Puerto Rico
Blue Cross & Blue Shield of Delaware 
California Medi-Cal
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
Montana Medicaid
Nebraska Medicaid
Nevada Medicaid
Plan de Salud Hospital Menonita
Plan de Salud Menonita Vital
Triple-S Advantage
Triple-S Salud
Utah Medicaid
Vermont Medicaid VT

Claim Status Enrollment Forms

Nebraska Medicaid
Nevada Medicaid
New York Medicaid
North Carolina Medicaid
Utah Medicaid

CX093 - Dental Select - ERA

84147 - CHAMPVA Dental - ERA

94146 - Medi-Cal Dental - Claims

94146 - Medi-Cal Dental - ERA

36215 - CENTRAL STATES HEALTH AND WELFARE FUNDS TEAMCARE - ERA

VAICE - DIVISION OF IMMIGRATION HEALTH SERVICES - ERA

CKME1 - Maine Medicaid - ERA

52133 - United Healthcare Dental - ERA

25849 - EAST BOSTON NEIGHBORHOOD PACE - ERA

BEAM1 - BEAM DENTAL INSURANCE - ERA

41101 - MIDWEST DENTAL BENEFITS - ERA

CBAL1 - BLUE CROSS AND BLUE SHIELD OF ALABAMA - ERA

65978 - METLIFE DENTAL – ERA

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

R7005 - MN POWER - ERA

R7002 - WILSON MCSHANE - 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

R7001 - ZENITH ADMIN – ERA

CDND1 - NORTH DAKOTA DELTA DENTAL - ERA

72153 - GROUP BENEFIT ADMINISTRATORS, INC - ERA

ARCMS - AR MEDICARE ADV - ERA

R7003 - BENEFIT INC – ERA

CDMI0 - MICHIGAN DELTA DENTAL - ERA

WIMAN - WI MEDICARE ADV - ERA

CX026 - MEDICA OF MN – ERA

CKNC1 - NCTRACKS (NC MEDICAID DIRECT) – CLAIMS

31117 - SUPERIOR DENTAL -ERA

CKND1 - NORTH DAKOTA MEDICAID - ERA

SKYGN - SKYGEN USA - ERA

96938 - SCION GATEWAY - ERA

SCION - SCION DENTAL - ERA

23281 – UPMC - ERA

MGDBP - MOONLIGHT GRAHAM - ERA

SDCOM - SCION COMMERCIAL - ERA

PACLF - PACIFIC LIFE - ERA

GHP22 - GEISINGER SKYGEN - ERA

UPMCD - UPMCD VIA SKYGEN - ERA

TLZ04 - CYPRESS ANCILLARY - ERA

22099 - HORIZON HEALTHCARE DENTAL SERVICES - ERA

CKNV1 - MEDICAID OF NEVADA - ERA

CKNV1 - MEDICAID OF NEVADA - CLAIMS

CKNJ1 - NEW JERSEY MEDICAID - ERA

CKNJ1 - NEW JERSEY MEDICAID - CLAIMS

CKDE1 - DELAWARE MEDICAID - ERA

CKKY1 - KENTUCKY MEDICAID - ERA

CKKS1 - KANSAS MEDICAID - ERA

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

CKDC1 - District of Columbia Medicaid - ERA

CKMN1 - MINNESOTA MEDICAID - ERA

CKMN1 - MINNESOTA MEDICAID - Claims

00390 - BCBS Tennessee - CLAIMS

00230 - BCBS Mississippi - CLAIMS

CKIN1 - Indiana Medicaid - ERA

00066 - WYOMING MEDICAID - ERA

00066 - WYOMING MEDICAID - CLAIMS

38520 - South Carolina Blue Cross Blue Shield - ERA

68246- AETNA ENCOUNTERS- ERA

60054 - AETNA - ERA

ZELIS - Zelis - ERA

ABHK1 - Aetna Better Health of Kentucky - ERA