Payer Enrollment Forms

Some payers require pre-enrollment before permitting the provider to submit electronic claims to them.  Typically payers such as Medicare, Medicaid, Blue Cross, and Blue Shield require pre-enrollment.  Payers that require pre-enrollment are indicated on our Payer Lists (PreEnr column).  As a service to our customers, Office Ally provides these agreements and forms below, pre-filled with Office Ally’s information whereever required.  Below is a list of all Pre-Enrollment forms available (sorted by state and payer). 

Be sure to complete the form(s) as indicated on the Instructions Cover Page to ensure applications are not denied for incorrect/missing information.

ALL or Multiple States Payer Enrollment Forms 

Payer Enrollment Forms for State Specific Payers:
AL | AK | AZ | AR | CA | CO | CT | DE | FL | GA | HI | ID | IL | IN | IA | KS | KY | LA | ME | MD
MA | MI | MN | MS | MO | MT | NE | NV | NH | NJ | NM | NY | NC | ND | OH | OK | OR | PA | RI | SC
SD | TN | TX | UT | VT | VA | WA | DC | WV | WI | WY

Electronic Remittance / ERA / 835 Enrollment Forms

All or Multiple States Payer Enrollment Forms

• Cahaba GBA Part A – 10301
• DMERC Region A (CT, DE, DISTRICT OF COLUMBIA, ME, MD, MA, NH, NJ, NY, PA, RI, VT)
• DMERC Region B (IL, IN, KY, MI, MN, OH, WI)
• DMERC Region C (AL, AR, CO, GA, FL, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV)
• DMERC Region D (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA,WY)
• Global Health
• Railroad Medicare EDI Enrollment Form
• TriCare for Life
• TriCare Overseas
• US Department of Labor
• Value Options
• WPS Legacy J04901

Alabama

• Medicare - AL
• Blue Cross Blue Shield – AL

Alaska

• Medicare Part B – AK
• Medicaid – AK
• Premera Blue Cross Blue Shield – AK

Arizona

• Medicare Part B – AZ

Arkansas

• Medicare – AR
• Blue Cross Blue Shield – AR
   

California

• Accountable Healthcare IPA
• Denti-Cal
• Los Angeles Medical Center
• Medi-Cal
• Medicare – California EFT Form
• Medicare Part A – CA
• Medicare Part B – CA NORTH
• Medicare Part B – CA SOUTH
• Sharp Community Medical Group Instructions
• Valley Health Plan (Commercial and Medi-Cal)

Colorado

• Medicaid – CO
• Medicaid Behavioral Health – CO
• Medicare (Part A) – CO
• Medicare (Part B) – CO
• Rocky Mountain

Connecticut

• Medicare – CT
• Medicaid - CT

Delaware

• Amerihealth (HMO)
• Amerihealth (Non-HMO)
• Blue Cross Blue Shield – DE
• Medicare – DE
• Medicaid - DE

Back to top Florida

• Medicaid – FL
• Medicare – FL

Georgia

• Medicaid - GA
• Medicare – GA

Hawaii

• Blue Cross Blue Shield – HI
• Medicaid - HI
• Medicare – HI
• Medicare EFT Form – HI
• University Health Alliance (UHA) - HI

Idaho

• Blue Cross - ID (ADA)
• Medicare - ID

Illinois

• Medicaid - IL
• Medicare - IL

Indiana

• Medicare - IN

Iowa

• Blue Cross Blue Shield - IA
• Medicare - IA
• Medicaid Part B- IA

Kansas

• Blue Cross Blue Shield - KS 
• Medicare - KS

Kentucky

• Medicaid - KY
• Medicare - KY

Louisiana

• Blue Cross Blue Shield - LA
• Medicare - LA
• Medicaid - LA

Maine

• Medicare - ME

Maryland

• Medicaid MHS (PMHS) - MD
• Medicaid - MD
• Medicare - MD

Massachusetts

• Blue Cross Blue Shield - MA
• Medicare - MA
• Medicaid Behavioral Health - MA
• TUFTS Health Plan - MA

Michigan

• Blue Cross Blue Shield - MI
• Medicare - MI
• Medicaid - MI

Minnesota

• HealthPartners of Minnesota
• Medicaid - MN (Instructions)
• Medicaid - MN (Provider Setup Form)
• Medicare - MN

Mississippi

• Blue Cross Blue Shield - MS
• Medicaid - MS
• Medicare - MS

Missouri

• Blue Cross Blue Shield Kansas City - MO
• Medicare (East & West) - MO

Montana

• Blue Cross Blue Shield - MT
• Medicare - MT

Nebraska

• Medicare - NE
• Medicaid - NE

Nevada

• Medicaid - NV
• Medicare - NV
• Medicare - NV (EFT Form)

New Hampshire

• Medicaid  - NH
• Medicare  - NH

New Jersey

• Amerihealth (HMO)
• Amerihealth (Non-HMO)
• Blue Cross Blue Shield - NJ (Dental)
• Medicaid - NJ
• Medicare - NJ

New Mexico

• Medicare - NM

Back to top New York

• Blue Cross Blue Shield Excellus – Central Region NY
• Blue Cross Blue Shield Excellus – Rochester NY
• Blue Cross Blue Shield Excellus – Utica Region NY
• BlueCross BlueShield of Western EDI Enrollment Form (NOT same as Empire BCBS) - NY
• BlueShield of Northeastern EDI Enrollment Form (NOT same as Empire BCBS) - NY
• Health Now - NY
• Medicare (Downstate Region) - NY
• Medicare (Queens County) - NY
• Medicare (Upstate County) - NY
• Medicaid - NY
• Univera Healthcare - NY

North Carolina

• Blue Cross Blue Shield - NC
• Medicare Palmetto - NC
• Partners Behavioral Health - NC
• Western Highlands Network - NC

North Dakota

• Blue Shield - ND
• Medicare Part B - ND

Ohio

• Medicare - OH

Oklahoma

• Medicare - OK

Oregon

• Lifewise Health Plan of Oregon
• Medicaid - OR
• Medicare Part B - OR

Pennsylvania

• Amerihealth Administrator
• Blue Cross Blue Shield (Highmark) - PA
• Capital Blue Cross/Keystone Health Plan Central
• Independence Blue Cross
• Keystone Health Plan East
• Medicare - PA

Rhode Island

• Blue Cross Blue Shield - RI
• Medicare - RI
• Medicaid - RI

South Carolina

• Medicaid - SC
• Medicare - SC

South Dakota

• Blue Cross Blue Shield - SD
• Medicare Part B - SD
• Medicaid - SD

Tennessee

• Blue Cross Blue Shield - TN
• Medicare Part A - TN
• Medicare Part B - TN

Texas

• Medicare (Part A) - TX
• Medicare (Part B) - TX

Utah

• Deseret Mutual Benefit Administrators - UT
• EMI Health - UT
• Medicare Part B - UT
• Public Employees Health Plan (PEHP) - UT
• Select Health of Utah - UT
• University of Utah - UT

Vermont

• Medicaid - VT
• Medicare - VT

Virginia

• Amerigroup of Virginia - VA
• Medicare - VA (City of Alexandria and Counties of Arlington & Fairfax Only)
• Medicare - VA (All Cities/Counties, Except Alexandria, Arlington & Fairfax)
• Virginia Premier

Virgin Islands              

• Medicare - VI

Washington

• Lifewise Health Plan of Washington
• Premera
• Medicaid (Provider One) - WA
• Medicare Parts A & B - WA

Washington DC

• Medicare - WA DC
• Medicaid - WA DC

West Virginia

• Medicare - WV
• Blue Cross Blue Shield - WV
• Blue Cross Blue Shield/Mountain States - WV
• Freedom Blue - WV

Wisconsin

• Medicare - WI

Wyoming

• Blue Shield  - WY
• Medicare Part B  - WY
• Medicaid - WY

Back to top Electronic Remittance / ERA / 835 Enrollment Forms  

• 1199 835 ERA
• AARP 835 ERA
• Accountable Behavioral Health 835 ERA
• Advantra Freedom 835 ERA
• Aetna 835 ERA & EFT
• Aetna Dental 835 ERA
• American International Group 835 ERA
• American Medical Security 835 ERA
• AmeriChoice APIPA (Arizona Physicians IPA) 835 ERA
• AmeriChoice of Maryland 835 ERA
• AmeriChoice of Nebraska 835 ERA
• AmeriChoice of New Jersey 835 ERA
• AmeriChoice of New York 835 ERA
• AmeriChoice of Tennessee 835 ERA
• AmeriChoice of Texas 835 ERA
• AmeriChoice of Wisconsin 835 ERA
• Amerigroup - Virginia 835 ERA
• Arkansas Best Corp - Choice Benefits 835 ERA
• Asuris Northwest Health 835 ERA
• Avera 835 ERA
• Blue Choice of South Carolina 835 ERA
• Blue Cross Blue Shield Alabama 835 ERA
• Blue Cross Blue Shield Arizona 835 ERA
• Blue Cross Blue Shield Arkansas 835 ERA
• Blue Cross Blue Shield Connecticut 835 ERA
• Blue Cross Blue Shield Delaware 835 ERA
• Blue Cross Blue Shield Florida 835 ERA
• Blue Cross Blue Shield Georgia 835 ERA
• Blue Cross Blue Shield Illinois 835 ERA
• Blue Cross Blue Shield Indiana 835 ERA
• Blue Cross Blue Shield Kansas 835 ERA
• Blue Cross Blue Shield Kentucky 835 ERA
• Blue Cross Blue Shield Maine 835 ERA
• Blue Cross Blue Shield Massachusetts 835 ERA
• Blue Cross Blue Shield / Care First - Maryland 835 ERA
• Blue Cross Blue Shield Michigan 835 ERA
• Blue Cross Blue Shield Minnesota 835 ERA
• Blue Cross Blue Shield Mississippi 835 ERA
• Blue Cross Blue Shield Missouri 835 ERA
• Blue Cross Blue Shield Montana 835 ERA
• Blue Cross Blue Shield Nebraska 835 ERA
• Blue Cross Blue Shield / Care First - DC/NCA Region 835 ERA
• Blue Cross Blue Shield Nevada 835 ERA
• Blue Cross Blue Shield New York - Central Region 835 ERA
• Blue Cross Blue Shield New York - Empire 835 ERA
• Blue Cross Blue Shield New York - Rochester Region 835 ERA
• Blue Cross Blue Shield New York - Utica Region 835 ERA
• Blue Cross Blue Shield New Hampshire 835 ERA
• Blue Cross Blue Shield New Mexico 835 ERA
• Blue Cross Blue Shield North Carolina 835 ERA
• BlueCross BlueShield of Western New York 835 ERA
• Blue Cross Blue Shield Ohio 835 ERA
• Blue Cross Blue Shield Oklahoma 835 ERA
• Blue Cross Blue Shield Pennsylvania 835 ERA
• Blue Cross Blue Shield Rhode Island 835 ERA
• Blue Cross Blue Shield South Carolina 835 ERA
• Blue Cross Blue Shield Tennessee 835 ERA
• Blue Cross Blue Shield Texas 835 ERA
• Blue Cross Blue Shield Vermont 835 ERA
• Blue Cross Blue Shield Virginia 835 ERA
• Blue Cross Blue Shield Wisconsin 835 ERA
• Blue Cross Blue Shield West Virginia 835 ERA
• Blue Cross Blue Shield West Vigrinia/ Mountain States 835 ERA
• Blue Cross California 835 ERA
• Blue Cross Colorado 835 ERA
• Blue Shield California ERA Attachment for Mulitple Tax IDs
• Blue Shield of California EFT & ERA
• Blue Shield of North Dakota 835 ERA
• BlueShield Northeastern New York 835 ERA
• Blue Shield of Wyoming 835 ERA
• Bravo Health 835 ERA
• Brown and Toland 835 ERA
• Capital Blue Cross/Keystone Health Plan Central 835 ERA
• Capital District Physicians Health Plan (CDPHP) 835 ERA
• Cariten 835 ERA
• Cariten Senior Health 835 ERA
• Central California Alliance for Health 835 ERA
• Chiropractic Health Plans 835 ERA
• Cigna 835 ERA
• Cigna EFT
• Clackamas County Medicaid Mental Health 835 ERA
• DakotaCare 835 ERA
• Definity Health Plan 835 ERA
• DMERC Region A 835 ERA
• DMERC Region B 835 ERA
• DMERC Region C 835 ERA
• DMERC Region D 835 ERA
• Evercare 835 ERA
• Everest Administrators 835 ERA
• Family Care Coordinated Care Organization 835 ERA
• Federated Mutual Health Insurance Company 835 ERA
• Firstcare and Firstcare Medicaid
• Fiserv Health - Wasau Benefits Benesight (UMR-Wausau/UHIS)
• GEHA 835 ERA
• Geisinger Health Plans 835 ERA
• GHI - New York (Group Health Inc.) 835 ERA
• Goldon Rule ERA
• Great Oregon Behavioral Health Inc 835 ERA
• Great-West Healthcare 835 ERA
• Group Health Cooperative 835 ERA
• Harvard Pilgrim 835 ERA
• Health Choice Arizona 835 ERA
• Health Now New York 835 ERA
• Health Partners MN 835 ERA
• Health Services Management (HSM) 835 ERA
• HealthCare Partners - CA & AZ 835 ERA
• HealthFirst 835 ERA
• Health Net Arizona 835 ERA
• Health Net of CA, OR 835 ERA
• Health Net of the Northeast Inc 835 ERA
• HealthPartners of MN (Dental) 835 ERA
• HIP Health Plan of NY 835 ERA
• Horizon Blue Cross Blue Shield of New Jersey/New York 835 ERA
• Horizon New Jersey Health Plan 835 ERA
• Humana 835 ERA
• Kaiser Foundation Health Plan of Colorado 835 ERA
• Kaiser Health Plan of the Mid-Atlantic States (MD, VA, DC) 835 ERA
• Kaiser Northern California 835 ERA
• Kaiser Southern California 835 ERA
• Kaiser NW Region 835 ERA
• LA Care 835 ERA
• Landmark/ChiroCare of MN 835 ERA
• LaneCare Medicaid Mental Health 835 ERA
• Lifewise Health Plan of OR 835 ERA
• Lifewise Health Plan of WA 835 ERA
• Magellan Behavioral Health 835 ERA
• Managed Health Services - 835 ERA
• Marion Polk Community Health Plan 835 ERA
• Marion Polk Community Health Plan Advantage 835 ERA
• Mayo Management Services, Inc (MMSI) 835 ERA
• Medica 835 ERA
• Medicaid Alabama 835 ERA
• Medicaid Alaska 835 ERA
• Medicaid Arkansas 835 ERA
• Medicaid Arizona 835 ERA
• Medicaid Colorado 835 ERA
• Medicaid Connecticut 835 ERA
• Medicaid Georgia Dental 835 ERA
• Medicaid Hawaii 835 ERA
• Medicaid Iowa 835 ERA
• Medicaid Indiana 835 ERA
• Medicaid Kentucky 835 ERA
• Medicaid Maine 835 ERA
• Medicaid Michigan 835 ERA
• Medicaid Minnesota 835 ERA
• Medicaid Missouri 835 ERA
• Medicaid Montana 835 ERA
• Medicaid Nevada 835 ERA
• Medicaid New Jersey 835 ERA
• Medicaid New Hampshire 835 ERA
• Medicaid New York 835 ERA
• Medicaid North Carolina 835 ERA
• Medicaid Ohio 835 ERA
• Medicaid Oklahoma 835 ERA
• Medicaid Oregon 835 ERA
• Medicaid Pennsylvania 835 ERA
• Medicaid South Carolina (Blue Choice) 835 ERA
• Medicaid Texas 835 ERA
• Medicaid Vermont 835 ERA
• Medicaid Virginia 835 ERA
• Medicaid West Virginia 835 ERA
• Medicaid Wisconsin 835 ERA
• MediCal 835 ERA
• Medical Mutual of Ohio 835 ERA
• Medicare Alaska 835 ERA
• Medicare Arizona 835 ERA
• Medicare CA North Part B J1 835 ERA
• Medicare CA Part A J1 835 ERA
• Medicare CA South Part B J1 835 ERA
• Medicare Connecticut 835 ERA
• Medicare Florida 835 ERA
• Medicare Hawaii (Palmetto) 835 ERA
• Medicare Idaho 835 ERA
• Medicare Illinois 835 ERA
• Medicare Indiana 835 ERA
• Medicare Iowa 835 ERA
• Medicare Kansas 835 ERA
• Medicare Kentucky 835 ERA
• Medicare Maine 835 ERA
• Medicare Massachusetts 835 ERA
• Medicare Michigan 835 ERA
• Medicare Minnesota 835 ERA
• Medicare Missouri East and West 835 ERA
• Medicare Montana 835 ERA
• Medicare Nebraska 835 ERA
• Medicare Nevada (Palmetto) 835 ERA
• Medicare New Hampshire 835 ERA
• Medicare North Carolina 835 ERA
• Medicare North Dakota 835 ERA
• Medicare NY Queens 835 ERA
• Medicare NY-Downstate 835 ERA
• Medicare NY-Upstate 835 ERA
• Medicare Oregon 835 ERA
• Medicare Rhode Island 835 ERA
• Medicare South Carolina 835 ERA
• Medicare South Dakota 835 ERA
• Medicare Utah 835 ERA
• Medicare Vermont 835 ERA
• Medicare Virginia (Palmetto) 835 ERA
• Medicare Virgin Islands 835 ERA
• Medicare Washington 835 ERA
• Medicare West Virginia (Palmetto) 835 ERA
• Medicare Wisconsin 835 ERA
• Medicare Wyoming 835 ERA
• Metropolitan Health Plan (MHP) 835 ERA
• MHNet 835 ERA
• Mid-West National Life Insurance Company of TN 835 ERA
• Midwest Security 835 ERA
• Moda Health (Formerly ODS Health Plan) 835 ERA
• Mohawk Valley (MVP) Health Plan 835 ERA
• Mid-Valley Behavioral Health Network 835 ERA
• Network Health 835 ERA
• Mutual of Omaha Ins. Company 835 ERA
• Nationwide Health Plan 835 ERA
• Optumhealth New Mexico
• Oxford Health Plan 835 ERA
• PacifiCare (HMO Claims Only) 835 ERA
• PacifiCare of AZ (Commerical HMO Claims Only) 835 ERA
• PacifiCare of CO
• PacificSource 835 ERA
• PacificSource Community DJC CD835 ERA
• PacificSource Community Solutions, Inc 835 ERA
• PacificSource Community Solutions Mental Health 835 ERA
• Paramount Health Care 835 ERA
• Peach State Health Plan 835 ERA
• Peoples Health Network 835 ERA
• PHP TennCare 835 ERA
• PreferredOne 835 ERA
• Premera of Blue Cross WA 835 ERA
• Premera Blue Cross Blue Shield AK 835 ERA
• Prime West 835 ERA
• Principle 835 ERA
• Providence Health Plan 835 ERA
• Regence Blue Cross Blue Shield OR 835 ERA
• Regence Blue Cross Blue Shield UT 835 ERA
• Regence Blue Shield ID 835 ERA
• Regence Blue Shield WA 835 ERA
• Sanford Health Plan 835 ERA
• SCAN CA, AZ 835 ERA
• Secure Horizon Direct 835 ERA
• Sierra Health Services 835 ERA
• State Farm Payer 31053 835 ERA
• State Farm Property & Casualty Payer 31059 835 ERA
• Superior Health Plan 835 ERA
• The MEGA Life Health Ins. Company 835 ERA
• Touchpoint 835 ERA
• Travelers 835 ERA
• Tricare for Life 835 ERA
• Tricare North, South and West 835 ERA
• Tricare Overseas
• TUFTS Health Plan 835 ERA
• UMR Wausau UHIS 835 ERA
• UniCare 835 ERA
• Unison Health Plan 835 ERA
• United Concordia - Blue Shield of PA (UCCI) 835 ERA
• United Concordia – Blue Shield of PA – Dental Plus- (UCCI) 835 ERA
• United Concordia – Fee for Service (UCCI) 835 ERA
• United Concordia – FMDP (Champus)- (UCCI) 835 ERA
• United Healthcare Commercial 835 ERA
• United Healthcare Military & Veterans 835 ERA
• United Healthcare of Pennsylvania 835 ERA
• United Heathcare of the River Valley 835 ERA
• United of Omaha 835 ERA
• Univera Healthcare 835 ERA
• University Physicians Healthcare 835 ERA
• UPMC Health Plan 835 ERA
• US Family Health Plan 835 ERA
• Verity - Medicaid Mental Health 835 ERA
• Verity Plus - Medicaid Mental Health 835 ERA
• Virginia Premier Health 835 ERA
• Washington County Medicaid Mental Health 835 ERA
• Western Highlands Network 835 ERA
• Wisconsin Physicians Services Commercial 835 ERA
• Wisconsin Physicians Services HIRSP 835 ERA

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