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Medical/Hospital Enrollment -
Institutional Claims Enrollment Forms

  Title Payer ID State(s)
  Tricare West - 12C01 - Inst Claims 12C01
  Massachusetts Medicaid - 12K14 - Inst Claims 12K14
  • Massachusetts
  New Mexico Medicare - 12M22 - Inst Claim 12M22
  • New Mexico
  New Jersey Medicaid - 12006 - Inst Claims 12006
  • New Jersey
  FTP TSO Request Form
  Claims Provider Setup Form
  Claims Change Delete Form
  New Jersey Medicare - 12005 - Inst Claim 12005
  • New Jersey
  Maryland Medicare - 12010 - Inst Claim 12010
  • Maryland
  J12 Highmark for DC, DE, MD, NJ, and PA – J12901 - Legacy - 12M99 - Inst Claim 12M99
  • Delaware
  • District of Columbia
  • Maryland
  • New Jersey
  • Pennsylvania
  DC Medicare - 12M63 - Inst Claims 12M63
  • District of Columbia
  Delaware Medicare - 12M76 - Inst Claims 12M76
  • Delaware
  Pennsylvania Medicare - 12M60 - Inst Claim 12M60
  • Pennsylvania
  Colorado Medicaid - 12K03 - Inst Claims 12K03
  • Colorado
  Mississippi BCBS & Teachers Blue - 12B17 - Inst Claims 12B17
  • Mississippi
  Home Health & Hospice J11 - 12M80 - Inst Claim 12M80
  • Alabama
  • Arkansas
  • Florida
  • Georgia
  • Illinois
  • Indiana
  • Kentucky
  • Louisiana
  • Mississippi
  • New Mexico
  • North Carolina
  • Ohio
  • Oklahoma
  • South Carolina
  • Tennessee
  • Texas
  South Carolina Medicare - 12M55 - Inst Claims 12M55
  • South Carolina
  North Carolina Medicare - 12M23 - Inst Claims 12M23
  • North Carolina
  Freedom Blue - 12B44 - Inst Claims 12B44
  • West Virginia
  CA Home Health & Hospice - 12M98 Inst Claims 12M98
  • California
  California Medicaid - 57016 - Inst Claims 57016
  • California
  California Medicaid "Claimmaster Clients Only" - 57016 - Inst Claim 57016
  • California
  District of Columbia Medicaid - 12001 - Inst Claim 12001
  • District of Columbia
  Amerihealth HMO Administrators NJ and DE - 23037 - Inst Claims 23037
  • Delaware
  • New Jersey
  Oregon Medicaid - 12K41 - Inst Claims 12K41
  • Oregon
  Lousiana Medicaid - 12K12 - Inst Claim 12K12
  • Louisiana
  Security Health Plan - 39045 - Inst Claims 39045
  Tricare South - 61125 - Inst Claims 61125
  • Alabama
  • Arkansas
  • Florida
  • Georgia
  • Louisiana
  • Mississippi
  • Oklahoma
  • South Carolina
  • Tennessee
  • Texas
  Delaware Medicaid - 12K87 - Inst Claims 12K87
  • Delaware
  Tennessee Medicare - 12M53 - Inst Claims 12M53
  • Tennessee
  Georgia Medicare - 12M05 - Inst Claim 12M05
  • Georgia
  Alabama Medicare - 12M01 - Inst Claim 12M01
  • Alabama
  Utah Medicaid - 12K42 - Inst Claims 12K42
  • Utah
  Maine Medicaid - 12K13 - Inst Claim 12K13
  • Maine
  Arkansas Medicare - 12022 - Inst Claim 12022
  • Arkansas
  Mississippi Medicare - 12M17 - Inst Claim 12M17
  • Mississippi
  Oklahoma Medicare - 12M37 - Inst Claims 12M37
  • Oklahoma
  Colorado Medicare - 12M03 - Inst Claim 12M03
  • Colorado
  Texas Medicare - 12M31 - Inst Claim 12M31
  • Texas
  Louisiana Medicare - 12M12 - Inst Claims 12M12
  • Louisiana
  Legacy Medicare - CO - TX - NM - OK – J40911 - 12M88 - Inst Claim 12M88
  • Colorado
  • New Mexico
  • Oklahoma
  • Texas
  New York Medicare - 12M35 - Inst Claims 12M35
  • New York
  Connecticut Medicare - 12M04 - Inst Claims 12M04
  • Connecticut
  West Virginia Medicare - 12M28 - Inst Claims 12M28
  • West Virginia
  Virginia Medicare - 12004 – Inst Claims 12004
  • Virginia
  Medicare Home Health & Hospice - 12HHA - Inst Claims 12HHA
  • Alaska
  • American Samoa
  • Arizona
  • California
  • Guam
  • Hawaii
  • Idaho
  • Michigan
  • Minnesota
  • Nevada
  • New Jersey
  • New York
  • Northern Marianas
  • Oregon
  • Puerto Rico
  • Virgin Islands
  • Washington
  • Wisconsin
  Minnesota Medicare - 12M16 - Inst Claims 12M16
  • Minnesota
  New Hampshire Medicare - 12M21 - Inst Claims 12M21
  • New Hampshire
  Massachusetts Medicare - 12M14 - Inst Claims 12M14
  • Massachusetts
  Maine Medicare - 12M13 - Inst Claims 12M13
  • Maine
  Rhode Island Medicare - 12M74 - Inst Claims 12M74
  • Rhode Island
  Vermont Medicare - 12M26 - Inst Claims 12M26
  • Vermont
  Illinois Medicare - 12M08 - Inst Claims 12M08
  • Illinois
  Penn Behavioral Health - 53226 - Inst Claims 53226
  Amerihealth PPO NJ - 12X28 - Inst Claims 12X28
  • New Jersey
  Amerihealth Administrators - 54763 - Inst Claims 54763
  WPS Health Insurance - 12X29 - Inst Claim 12X29
  PEHP - 12X36 - Inst Claims 12X36
  Hawaii BCBS - 12B62 - Inst Claims 12B62
  • Hawaii
  Tricare Overseas - 12X46 - Inst Claims 12X46
  Tricare North - 57106 - Inst Claim 57106
  • Connecticut
  • Delaware
  • District of Columbia
  • Illinois
  • Indiana
  • Kentucky
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • New Hampshire
  • New Jersey
  • North Carolina
  • Ohio
  • Rhode Island
  • Vermont
  • Virginia
  • West Virginia
  • Wisconsin
  CGS Home Health - 12M97 - Inst Claim 12M97
  • Alabama
  • Colorado
  • Delaware
  • District of Columbia
  • Iowa
  • Kansas
  • Maryland
  • Missouri
  • Montana
  • Nebraska
  • North Dakota
  • Pennsylvania
  • South Dakota
  • Utah
  • Virginia
  • West Virginia
  • Wyoming
  Ohio Medicare – 12M24 – Inst Claims 12M24
  • Ohio
  Kentucky Medicare - 12M11 - Inst Claim 12M11
  • Kentucky
  Tufts Network Health – 04332 – Inst Claims 04332
  Florida Medicare - 12M34 - Inst Claim 12M34
  • Florida
  Puerto Rico Medicare - 12M49 - Inst Claims 12M49
  • Puerto Rico
  US Virgin Islands Medicare - 12M52 - Inst Claim 12M52
  • Virgin Islands
  ValueOptions/MBHP (MA Behavioral Health Partnership - 43307 - Inst Claims 43307
  • Massachusetts
  Value Optiosn (TX NorthStar) - 99297 - Inst Claims 99297
  • Texas
  Value Options - 12X56 - Inst Claim 12X56
  Value Options - 12K1A - Inst Claims 12K1A
  Oregon Medicare - 12M41 - Inst Claim 12M41
  • Oregon
  North Dakota BC - 12B78 - Inst Claim 12B78
  • North Dakota
  North Dakota Medicare - 12M82 - Inst Claim 12M82
  • North Dakota
  Montana Medicare - 12M77 - Inst Claim 12M77
  • Montana
  Iowa Medicaid - 12K10 - Inst Claim 12K10
  • Iowa
  Arizona Medicare - 12M02 - Inst Claim 12M02
  • Arizona
  AK & ID Medicare - 12M07 - Inst Claim 12M07
  • Alaska
  • Idaho
  Legacy Part A - CA - HI- NV - 12M65 - Inst Claim 12M65
  • California
  • Hawaii
  • Nevada
  Hawaii Medicare - 12M64 - Inst Claim 12M64
  • Hawaii
  California Medicare - 12M64 - Inst Claim 12M64
  • California
  Nevada Medicare - 12M64 - Inst Claim 12M64
  • Nevada
  Kentucky Medicaid - 12K11 - Inst Claims 12K11
  • Kentucky
  Tricare for Life - 12X43 - Inst Claim 12X43
  Michigan Medicare - 12M18 - Inst Claim 12M18
  • Michigan
  Indiana Medicare - 12M09 - Inst Claims 12M09
  • Indiana
  Legacy Medicare WPS J5 - 52280 - Inst Claims 52280
  • Iowa
  • Kansas
  • Michigan
  • Missouri
  • Nebraska
  Nebraska Medicare - 12M19 - Inst Claims 12M19
  • Nebraska
  Missouri Medicare - 12M15 - Inst Claim 12M15
  • Missouri
  Kansas Medicare - 57324 - Inst Claim 57324
  • Kansas
  Iowa Medicare - 12M10 - Inst Claim 12M10
  • Iowa
  Health Safety Network / MASS. Health Medicaid- 12K48 - Inst Claims 12K48
  • Massachusetts
  Partners Behavioral Health Management - 52613 - Inst Claim 52613
  IBC Personal Choice - 12X26 - Inst Claims 12X26
  Keystone Health Plan East /IBC - 12X25 - Inst Claims 12X25
  Nebraska Blue Shield - 12B19 - Inst Claims 12B19
  • Nebraska
  Illinois Medicaid - 12K08 - Inst Claims 12K08
  • Illinois
  South Dakota Medicaid - 12K36 - Inst Claims 12K36
  • South Dakota
  Wyoming Medicaid - 12K30 - Inst Claim 12K30
  • Wyoming
  Georgia Medicaid - 12K05 - Inst Claims 12K05
  • Georgia
  Florida Medicaid - 12K34 - Inst Claims 12K34
  • Florida
  Iowa BCBS - 12B10 - Inst Claims 12B10
  • Iowa
  South Dakota BCBS - 12B33 - Inst Claims 12B33
  • South Dakota
  Nebraska Medicaid - 12K19 - Inst Claims 12K19
  • Nebraska
  Capital Blue Cross - 12B61 - Inst Claim 12B61
  HealthPartners Minnesota Hospital - 12X51 - Inst Claims 12X51
  Wyoming BC - 12B30 - Inst Claim 12B30
  • Wyoming
  Wyoming Medicare - 12M30 - Inst Claim 12M30
  • Wyoming
  Washington Medicare - 12M45 - Inst Claim 12M45
  • Washington
  Utah Medicare - 12M84 - Inst Claim 12M84
  • Utah
  South Dakota Medicare - 12M83 - Inst Claim 12M83
  • South Dakota
  Michigan Medicaid Hospital - 12K37 - Inst Claims 12K37
  • Michigan
  Alaska Medicaid - 12K86 - Inst Claims 12K86
  • Alaska
  Vermont BCBS - 12B32 - Inst Claims 12B32
  • Vermont
  New York State Medicaid - 12K35 - Inst Claims 12K35
  • New York
  Idaho Blue Cross - 12B07 - Inst Claims 12B07
  • Idaho
  South Carolina Medicaid - 12K55 - Inst Claims 12K55
  • South Carolina
  Puerto Rico BCBS - 12B48 -Inst Claim 12B48
  • Puerto Rico
  Michigan BC - 12B18 - Inst Claim 12B18
  • Michigan
  Idaho True Blue - 12B84 - Inst Claims 12B84
  • Idaho
  Mississippi Medicaid - 12K17 - Inst Claims 12K17
  • Mississippi
  Health Adv/US Able/First Pyramid Life/Arkansas Blue Cross - 12049 - Inst Claims 12049
  • Arkansas
  Indiana State Dept of Health/CSHCS - 35600 - Inst Claims 35600
  • Indiana
  Arkansas Blue Cross - 12021 - Inst Claims 12021
  • Arkansas
  Rhode Island Medicaid Deactivation - 12K74 - Inst Claims 12K74
  • Rhode Island
  Tennessee Medicaid - 12K46 - Inst Claims 12K46
  • Tennessee
  Pennsylvania Western BC - 12B60 - Inst Claims 12B60
  • Pennsylvania
  Pennsylvania BCBS Central Highmark - 12B81 - Inst Claims 12B81
  • Pennsylvania
  West Virginia Blue Cross - 12B28 - Inst Claims 12B28
  • West Virginia
  Highmark Senior Solution - 95461 - Inst Claims 95461
  • West Virginia
  Rhode Island Medicaid Enrollment- 12K74 - Inst Claims 12K74
  • Rhode Island
  Virginia Premier - 12K83 - Inst Claims 12K83
  • Virginia
  Washington Medicaid Hospital - 12K27 - Inst Claims 12K27
  • Washington
  Carolina Crescent - 12K85 - Inst Claims 12K85
  Maryland Behavioral Health - 22322 - Inst Claims 22322
  • Maryland
  Delaware BC - 12B76 - Inst Claim 12B76
  • Delaware
  Hawaii Medicaid Hospital - 12K62 - Inst Claims 12K62
  • Hawaii
  Independent Health - 12X01 - Inst Claim 12X01
  Maryland Medicaid -- 12007 - Inst Claims 12007
  • Maryland
  HealthPlus of Michigan - 38216 - Inst Claims 38216
  • Michigan
  North Carolina Medicaid - 12K23 - Inst Claim 12K23
  • North Carolina
  Vermont Medicaid - 12K26 - Inst Claim 12K26
  • Vermont
  Michigan Blue Care Network - 12B58 - Inst Claims 12B58
  • Michigan
  New Jersey BCBS - 22099 - Inst Claims 22099
  • New Jersey
  Tennessee BC - 12B45-12B53 - Inst Claims 12B45
  • Tennessee
  Louisiana BCBS - 12B12 - Inst Claims 12B12
  • Louisiana
  Montana BCBS Hospital - 12B77 - Inst Claims 12B77
  • Montana
  Minnesota Medicaid - 12K16 - Inst Claims 12K16
  • Minnesota
  Partnership Health Plan of CA - 12M81 - Inst Claims 12M81
  • California
  Nevada Medicaid - 12K20 - Inst Claims 12K20
  • Nevada