Enrollment forms

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

• CHC MID/TID/TPG Creation Form – Initial request for a MID/TID or TPG

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
Highmark Blue Cross Blue Shield of West Virginia
Highmark Blue Cross Shield DE
Mapfre
Medical Card System (MCS)
Medicare Medex
Michigan Medicaid
MMM Healthcare (Reform)
Mountain State Blue Cross of West Virginia
Nebraska Medicaid
Nevada Medicaid
Medicare
Plan de Salud Hospital Menonita
Plan de Salud Menonita Vital
PMC Medicare Choice (reform)
Preferred Medicare Choice
Triple-S Advantage
Triple-S Salud
Utah Medicaid
Vermont Medicaid VT

Claim Status Enrollment Forms

Nebraska Medicaid
New York Medicaid
North Carolina Medicaid
Utah Medicaid

BBMDQ - Blue Cross of MI - CLAIMS

BBMDQ - Blue Cross of MI - ERA

70408 - Assurant Employee Benefits - ERA

70408 - Assurant Employee Benefits - CLAIMS

CX058 - Kansas City Life Insurance Company - ERA

CX058 - Kansas City Life Insurance Company - CLAIMS

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

SX110 – EMI HEALTH - CLAIMS

SX110 – EMI HEALTH - ERA

SX105 – DESERET MUTUAL BENEFIT ASSOCIATES (DMBA) - CLAIMS

SX105 – DESERET MUTUAL BENEFIT ASSOCIATES (DMBA) - ERA

SX106 – PUBLIC EMPLOYEE HEALTH PLAN (PEHP) - CLAIMS

SX106 – PUBLIC EMPLOYEE HEALTH PLAN (PEHP) - ERA

75261 – WEBTPA - ERA

56205 – MEDCOST BENEFIT SERVICES - ERA

CKKY3 - Kentucky Medicaid - Doral Dental - Region 3 - Claims

CKMD1 - Maryland Medicaid - Claims

CKSC1 - South Carolina Medicaid - Claims

CKVA1 - Virginia Medicaid - Claims

CX035 - Dental Care Plus of OH - Claims

04356 - DentaQuest - Claims

CX014 - Doral of Wisconsin - Claims

CX052 - ADI FDMG OF FL - Claims

62154 - Xantus Health Plan of Nashville TN - Claims

CKID1 - Idaho Medicaid - Claims

CKIL1 - Illinois Medicaid - Doral - Claims

CKKY3 - Kentucky Medicaid - Doral Dental - Region 3 - ERA

CKMD1 - Maryland Medicaid - ERA

CKSC1 - South Carolina Medicaid - ERA

CKVA1 - Virginia Medicaid - ERA

04356 - DENTAQUEST - ERA

CX014 - DORAL OF WISCONSIN - ERA

CX035 - DENTAL CARE PLUS OF OH - ERA

CX052 - ADI FDMG OF FL - ERA

CKIL1 - Illinois Medicaid - Doral - ERA

62154 - Xantus Health Plan of Nashville TN - ERA

CKID1 - Idaho Medicaid - ERA

CX030 - Safeguard PPO - ERA

CX048 -Safeguard HMO - ERA

70123 - SUN LIFE WV PEIA - CLAIMS

70123 - SUN LIFE WV PEIA - ERA

67814 - SUN LIFE AND HEALTH INSURANCE COMPANY - CLAIMS

67814 - SUN LIFE AND HEALTH INSURANCE COMPANY - ERA

CKMA1 - MASSHEALTH - CLAIMS

CKMA1 - MASSHEALTH - ERA

004766 - BKS-Medicaid of Kansas - ERA

004766 - EDS-Medicaid of Arkansas - ERA

004766 - EDS-Medicaid of California - ERA

004766 - EDS-Medicaid of Indiana - ERA

004766 - EDS-Medicaid of Wisconsin - ERA

004766 - Medicare Split Billing - ERA

002538-TMESYS-ERA

003241-EDS-Medicaid of Arkansas-ERA

003241-Employer Health Options-ERA

003573-EDS-Medicaid of Wisconsin-ERA

003573-Medicaid of Maine-ERA

003573-Third-Party Solutions-ERA

003585-DST-Health Solutions-ERA

003585-Express Scripts Value RX-DPS-ERA

003585-Medimpact-ERA

003585-Medone-ERA

003585-Optum RX-ERA

003585-Opus Health Information System-ERA

003585-Procare RX-ERA

004261-TMESYS-ERA

004303-Omnisys-ERA

004527-Employer Health Options-ERA

004583-BCBS of Mississippi-ERA

004682-Express Scripts Value RX-DPS-ERA

004682-Independent Health Plan-ERA

004682-Mede America Healtheon WEBMD-ERA

004682-Pharmacy Data Management-ERA

004682-Tmesys-ERA

004880-Employer Health Options-ERA

005285-Optum RX-ERA

005285-Procare RX-ERA

005500-Medimpact-ERA

005518-Medimpact-ERA

005567-Third-Party Solutions-ERA

006012-Pharmacy Data Management-ERA

006053-Medimpact-ERA

006053-Save RX-ERA

006086-Mede America-Healtheon WEBMD-ERA

008035-Procare RX-ERA

008266-Procare RX-ERA

009265-DST-Health Solutions-ERA

009265-Procare Rx-ERA

009430-Procare Rx-ERA

009620-Third-Party Solutions-ERA

010868-Optum RX-ERA

011131-Optum RX-ERA

011669-Procare RX-ERA

011834-DST-Health Solutions-ERA

011917-Medimpact-ERA

012323-DST-Health Solutions-ERA

012353-Anthem Prescription Management-ERA

012353-DST-Health Solutions-ERA

012353-Express Scripts Value RX-DPS

012353-Medimpact-ERA

012353-Optum RX-ERA

012493-Procare RX-ERA

012882-Medimpact-ERA

012965-Procare RX-ERA

013071-TMESYS-ERA

013105-Medimpact-ERA

013535-Pharmacy Data Management-ERA

013824-DST-Health Solutions-ERA

013832-Procare RX-ERA

014179-Express Scripts Value RX-DPS-ERA

014310-Procare RX-ERA

014575-Procare RX-ERA

014947-Mede America Healtheon WEBMD-ERA

014947-Optum RX-ERA

014955-Data RX Management-ERA

014955-Pharmacy Data Management-ERA

015235-Procare RX-ERA

015251-Mede America Healtheon WEBMD-ERA

015433-Express Scripts Value RX-DPS-ERA

015433-Southern Scripts-ERA

015441-Medimpact-ERA

015517-Medimpact-ERA

015558-Optum RX-ERA

015574-Medimpact-ERA

015581-DST-Health Solutions-ERA

015599-Express Scripts Value RX-DPS-ERA

015707-Mede America Healtheon WEBMD-ERA

015764-DST-Health Solutions-ERA

015764-Optum RX-ERA

015921-Medimpact-ERA

015921-Optum RX-ERA

015954-DST-Health Solutions-ERA

015995-Express Scripts Value RX-DPS-ERA

016085-Medimpact-ERA

016110-Pharmacy Data Management-ERA

016127-Navitus Hlth-ERA

016184-Mede America Healtheon WEBMD-ERA

016466-Scriptcycle-ERA

016549-Medimpact-ERA

016671-Medimpact-ERA

016689-Medimpact-ERA

016796-Medimpact-ERA

016912-Express Scripts Value RX-DPS-ERA

016961-DST-Health Solutions-ERA

016978-DST-Health Solutions-ERA

017010-Optum RX-ERA

017043-Procare RX-ERA

017142-Medimpact-ERA

017200-Elixir Solutions-ERA

017274-Pharmacy Data Management-ERA

017309-DST-Health Solutions-ERA

017309-Optum RX-ERA

017317-DST-Health Solutions-ERA

017324-Optum RX-ERA

017373-Scriptcycle-ERA

017423-Optum RX-ERA

017480-DST-Health Solutions-ERA

017515-Procare RX-ERA

017522-Simple Save RX-ERA

017564-Navitus Hlth-ERA

017688-EDS-Medicaid of Connecticut-ERA

017696-Medimpact-ERA

017713-Medimpact-ERA

017812-Procare RX-ERA

017878-DST-Health Solutions-ERA

018050-Blue Eagle Health-ERA

018050-Medimpact-ERA

018232-DST-Health Solutions-ERA

018265-DST-Health Solutions-ERA

018299-Procare RX-ERA

018315-Procare RX-ERA

018364-Procare RX-ERA

018596-Medimpact-ERA

018612-DST-Health Solutions-ERA

018753-Procare RX-ERA

018778-Procare RX-ERA

018803-DST-Health Solutions-ERA

018844-Optum RX-ERA

018927-DST-Health Solutions-ERA

019158-DST-Health Solutions-ERA

019272-Elixir Solutions-ERA

019439-DST-Health Solutions-ERA

019520-Medimpact-ERA

019629-Pharmacy Data Management-ERA

019653-DST-Health Solutions-ERA

019660-DST-Health Solutions-ERA

019678-DST-Health Solutions-ERA

019710-Employer Health Options-ERA

019786-Mede America Healtheon Webmd-ERA

020040-Employer Health Options-ERA

020271-Procare RX-ERA

020313-Procare RX-ERA

020545-First Health Medicaid Ohio-ERA

020750-Medimpact-ERA

020826-Procare RX-ERA

020859-Procare RX-ERA

020867-DST-Health Solutions-ERA

020974-Navitus Hlth-ERA

021031-Pharmacy Data Management-ERA

021056-Procare RX-ERA

021106-DST-Health Solutions-ERA

021148-Mede America Healtheon WEBMD-ERA

021171-Pharmacy Data Management-ERA

021288-ClaimRX (SUBSID of PRO-MARK)-ERA

021437-Procare RX-ERA

021700-Express Scripts Value RX-DPS

021932-Pharmacy Data Management-ERA

021940-Mede America Healtheon WEBMD-ERA

021981-Express Scripts Value RX-DPS-ERA

021981-Procare RX-ERA

022006-Navitus Hlth-ERA

022022-Navitus Hlth-ERA

022055-DST-Health Solutions-ERA

022071-DST-Health Solutions-ERA

022105-Express Scripts Value RX-DPS

022154-Mede America Healtheon WEBMD-ERA

022188-Procare RX-ERA

022220-Mede America Healtheon WEBMD-ERA

022279-Pharmacy Data Management-ERA

022733-Procare RX-ERA

022740-Procare RX-ERA

022816-Mckesson Healthcare Del Syst-ERA

022816-Monarch Brightscrip-ERA

022816-Procare RX-ERA

023211-Script Care Inc-ERA

023237-Procare RX-ERA

023609-Mede America Healtheon WEBMD-ERA

023781-Procare RX-ERA

023880-Medimpact-ERA

023906-Mede America Healtheon WEBMD-ERA

023947-Mede America Healtheon WEBMD-ERA

023971-Procare RX-ERA

024004-Navitus Hlth-ERA

024517-Pharmacy Data Management-ERA

024532-Mede America Healtheon WebMD-ERA

024748-Procare RX-ERA

024756-Procare RX-ERA

024789-Navitus Hlth-ERA

024847-Data RX Management-ERA

025227-Pharmacy Data Management-ERA

025409-Navitus Hlth-ERA

025432-Navitus Hlth-ERA

071225-Navitus Hlth-ERA

600426-Mede America Healtheon WEBMD-ERA

600426-Optum RX-ERA

600426-Prof Mgmt Development Corp-ERA

600428-Anthem Prescription Management-ERA

600428-Blue Cross Sheild Arkansas-ERA

600428-DST-Health Solutions-ERA

600428-Express Scripts Value RX-DPS-ERA

600428-Hawaii Med Serv Assoc Non-Medc-ERA

600428-McKesson Healthcare Del Sys-ERA

600428-Optum RX-ERA

600428-Propar Serv Prime Therapeutics-ERA

610020-Anthem Prescription Management-ERA

610020-Express Scripts Value RX-DPS-ERA

610020-Navitus Hlth-ERA

610020-Optum RX-ERA

610020-Pharmacy Data Management-ERA

610086-General Prescription Program-ERA

610106-Optum RX-ERA

610141-DST-Health Solutions-ERA

610141-Medicaid of Texas-ERA

610144-Express Scripts Value RX-DPS-ERA

610170-Procare RX-ERA

610186-Navitus Hlth-ERA

610198-DST-Health Solutions-ERA

610209-DST-Health Solutions-ERA

610220-DST-Health Solutions-ERA

610225-DST-Health Solutions-ERA

610245-DST-Health Solutions-ERA

610280-DST-Health Solutions-ERA

610312-Medimpact-ERA

610315-Relay Health -Pharmacy Solution-ERA

610475-Anthem Prescription Management-ERA

610475-Express Scripts Value RX-DPS-ERA

610475-Medimpact-ERA

610475-Medone-ERA

610489-Procare RX-ERA

610500-McKesson Healthcare Del Syst-ERA

610600-McKesson HealthCare Del Syst-ERA

610601-Procare RX-ERA

610602-Navitus Hlth-ERA

610602-Optum RX-ERA

610610-Medimpact-ERA

610631-DST-Health Solutions-ERA

610649-DST-Health Solutions-ERA

610709-DST-Health Solutions-ERA

610711-Procare RX-ERA

610719-Procare RX ERA

610728-DST-Health Solutions-ERA

610826-Navitus Hlth-ERA

637765-Elixir Solutions-ERA

637765-Mede America Healtheon WEBMD-ERA

808412-Medimpact-ERA

004245-Capital RX-ERA

001553-Optum-RX-ERA

004336-BC-BS-Texas-ERA

003650-Optum-RX-ERA

004336-Anthem-Prescription-Management-ERA

004336-Blue-Cross-Blue-Shield-Arkansas-ERA

004146-Alabama-Medicaid-ERA

003452-Optum-RX-ERA

003858-BCBS of Massachusetts-ERA

003858-BCBS of Michigan-ERA

009555-ACS Consultec-ERA

011875-Procare RX-ERA

011933-Medicaid of Iowa Noridian-ERA