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Medical/Hospital Enrollment -
Professional Claims Enrollment Forms

  Title Payer ID State(s)
  TriWest VAPC3 Region 6 - 55917 - Prof Claims 55917
  TriWest VAPC3 Region 5B - 55916 - Prof Claims 55916
  TriWest VAPC3 Region 5A - 55915 - Prof Claims 55915
  TriWest VAPC3 Region 3 - 55912 - Prof Claims 55912
  Delaware Medicaid - SKDE0 - Prof Claims SKDE0
  • Delaware
  GUILDNET - GLDNT - PROF CLAIMS GLDNT
  ATRIO FKA MARION POLK - MPCHA - PROF CLAIMS MPCHA
  • Oregon
  Aloha Advantage - ALOHA - Prof Claims ALOHA
  • Hawaii
  Alliance Behavioral Healthcare - 23071- Professional Claims 23071
  FTP TSO Request Form
  Claims Provider Setup Form
  Claims Change Delete Form
  South Carolina Medicare - SMSC0 - Prof Claims SMSC0
  • South Carolina
  West Virginia Medicare - SMWV0 - Prof Claims SMWV0
  • West Virginia
  North Carolina Medicare - SMNC0 - Prof Claims SMNC0
  • North Carolina
  Virginia Medicare - SMVA0 - Prof Claims SMVA0
  • Virginia
  California Medi-Cal Vision - SKCA1 - Prof Claim SKCA1
  • California
  California Medicaid - SKCA0 - Prof Claims SKCA0
  • California
  District of Columbia Medicaid - SKDC0 - Prof Claim SKDC0
  • District of Columbia
  Georgia Medicare - SMGA0 - Prof Claim SMGA0
  • Georgia
  Alabama Medicare - SMAL0 - Prof Claim SMAL0
  • Alabama
  Utah Medicaid - SKUT0 - Prof Claims SKUT0
  • Utah
  Maine Medicaid - SKME0 - Prof Claim SKME0
  • Maine
  Louisiana Medicare - SMLA0 - Prof Claims SMLA0
  • Louisiana
  Texas Medicare - SMTX0 - Prof Claim SMTX0
  • Texas
  Colorado Medicare – SMCO0 – Prof Claim SMCO0
  • Colorado
  Oklahoma Medicare - SMOK0 - Prof Claim SMOK0
  • Oklahoma
  Arkansas Medicare - SMAR0 - Prof Claim SMAR0
  • Arkansas
  Mississippi Medicare – SMMS0 – Prof Claim SMMS0
  • Mississippi
  New Mexico Medicare - SMNM0 - Prof Claims SMNM0
  • New Mexico
  Delaware Medicare - SMDE0 - Prof Claim SMDE0
  • Delaware
  District of Columbia Medicare - SMDC0 - Prof Claim SMDC0
  • District of Columbia
  Maryland Medicare - SMMD0 - Prof Claim SMMD0
  • Maryland
  New Jersey Medicare - SMNJ0 - Prof Claim SMNJ0
  • New Jersey
  Pennsylvania Medicare – SMPA0 – Prof Claim SMPA0
  • Pennsylvania
  Blue Care Network - SB711 - Prof Claims SB711
  • Michigan
  Colorado Medicaid - SKCO0 - Prof Claims SKCO0
  • Colorado
  Blue Cross Blue Shield Mississippi State and Teacher Employees - SB731 - Prof Claims SB731
  • Mississippi
  Mississippi BCBS - SB730 - Prof Claims SB730
  • Mississippi
  Massachusetts Medicare - SMMA0 - Prof Claims SMMA0
  • Massachusetts
  Maine Medicare - SMME0 - Prof Claims SMME0
  • Maine
  Rhode Island Medicare - SMRI0 - Prof Claims SMRI0
  • Rhode Island
  Railroad Medicare - SRRGA - Prof Claims SRRGA
  • ~All States
  Virginia Premier Health Plan - 54176 - Prof Claims 54176
  • Virginia
  Penn Behavioral Health - 53226 - Prof Claims 53226
  Amerihealth Administrators - 54763 - Prof Claims 54763
  Amerihealth HMO New Jersey and Delaware - 23037 - Prof Claims 23037
  • Delaware
  • New Jersey
  Amerihealth New Jersey Non HMO - SX075 - Prof Claims SX075
  • New Jersey
  Amerihealth Delaware Non HMO - SX074 - Prof Claims SX074
  Oregon Medicaid - SKOR0 - Prof Claim SKOR0
  • Oregon
  Louisiana Medicaid - SKLA0,_SKLA1, SKLA2, SKLA3 - Prof Claims SKLA0
  • Louisiana
  Security Health Plan - 39045 - Prof Claims 39045
  Tricare South - 61125 - Prof Claims 61125
  • Alabama
  • Arkansas
  • Florida
  • Georgia
  • Louisiana
  • Mississippi
  • Oklahoma
  • South Carolina
  • Tennessee
  • Texas
  Tennessee Medicare - SMTN0 - Prof Claim SMTN0
  • Tennessee
  Maryland Medicaid - SKMD0 - Prof Claims SKMD0
  • Maryland
  Hawaii Medicaid - SKHI0 - Prof Claims SKHI0
  • Hawaii
  Tricare Overseas - SX163 - Prof Claims SX163
  Nevada Medicaid - SKNV0 - Prof Claims SKNV0
  • Nevada
  Virgin Island Medicare - SMVI0 - Prof Claims SMVI0
  • Virgin Islands
  Puerto Rico Medicare - SMPR0 - Prof Claim SMPR0
  • Puerto Rico
  Florida Medicare - SMFL0 - Prof Claim SMFL0
  • Florida
  Value Options/ MBHP (MA Behavioral Health Partnership) - 43307 - Prof Claims 43307
  Value Options - SX173 - Prof Claims SX173
  WA State Dept of Labor and Industry - SX063 - Prof Claims SX063
  • Washington
  New York Medicare Empire - SMNY0 - Prof Claim SMNY0
  • New York
  New York Medicare Upstate - Western - SMNY1 - Prof Claim SMNY1
  • New York
  New York Medicare GHI - SMNY2 - Prof Claim SMNY2
  • New York
  Connecticut Medicare - SMCT0 - Prof Claim SMCT0
  • Connecticut
  Illinois Medicare - SMIL0 - Prof Claim SMIL0
  • Illinois
  Minnesota Medicare - SMMN0 - Prof Claim SMMN0
  • Minnesota
  Wisconsin Medicare - SMWI0 - Prof Claim SMWI0
  • Wisconsin
  Vermont Medicare - SMVT0 - Prof Claims SMVT0
  • Vermont
  New Hampshire Medicare - SMNH0 - Prof Claims SMNH0
  • New Hampshire
  Michigan Medicare - SMMI0 - Prof Claim SMMI0
  • Michigan
  Iowa Medicare - SMIA0 - Prof Claim SMIA0
  • Iowa
  Hawaii BCBS - SB971 - Prof Claims SB971
  • Hawaii
  Iowa BCBS - SB640 - Prof Claims SB640
  • Iowa
  Kansas Medicare - SMKS0 - Prof Claim SMKS0
  • Kansas
  Missouri Medicare - SMMO0 - Prof Claim SMMO0
  • Missouri
  Indiana Medicare - SMIN0 - Prof Claim SMIN0
  • Indiana
  WPS Commercial - SX022 - Prof Claims SX022
  Tricare for Life - SX176 - Prof Claim SX176
  TriCare West - SCWI0 - Prof Claims SCWI0
  • Alaska
  • Arizona
  • California
  • Colorado
  • Hawaii
  • Idaho
  • Iowa
  • Kansas
  • Minnesota
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • North Dakota
  • Oregon
  • South Dakota
  • Utah
  • Washington
  • Wyoming
  Pensylvania BC - SX079 - Prof Claims SX079
  • Pennsylvania
  Ohio Medicare - SMOH0 - Prof Claims SMOHO
  • Ohio
  Kentucky Medicare - SMKY0 - Prof Claims SMKY0
  • Kentucky
  HealthPlus of Michigan - 38216 - Prof Claims 38216
  • Michigan
  Health Services Management -41150 - Prof Claims 41150
  Maryland Behavioral Health - SX069 - Prof Claims SX069
  • Maryland
  Hawaii Medicaid Waviers - 77059 - Prof Claims 77059
  • Hawaii
  Wyoming Medicaid - SKWY0 - Prof Claims SKWY0
  • Wyoming
  New Jersey Medicaid - SKNJ0 - Prof Claims SKNJ0
  • New Jersey
  Idaho Medicare - SMID0 - Prof Claims SMID0
  • Idaho
  California Medicare South - SMCA2 - Prof Claims SMCA2
  • California
  California Medicare - SMCA1 - Prof Claims SMCA1
  • California
  Alaska Medicare - SMAK0 - Prof Claim SMAK0
  • Alaska
  Arizona Medicare - SMAZ0 - Prof Claim SMAZ0
  • Arizona
  DMERC Region A - SDMEA - Prof Claims SDMEA
  • Connecticut
  • Maine
  • Massachusetts
  • New Hampshire
  • New Jersey
  • New York
  • Pennsylvania
  • Rhode Island
  • Vermont
  DMERC Region B - SDMEB - Prof Claims SDMEB
  • Illinois
  • Indiana
  • Michigan
  • Minnesota
  • Ohio
  • Virginia
  • West Virginia
  • Wisconsin
  DMERC Region C - SDMEC - Prof Claim SDMEC
  • Alabama
  • Arkansas
  • Colorado
  • Florida
  • Georgia
  • Kentucky
  • Louisiana
  • Mississippi
  • New Mexico
  • North Carolina
  • Oklahoma
  • Puerto Rico
  • South Carolina
  • Tennessee
  • Texas
  DMERC Region D - SDMED - Prof Clams SDMED
  • Arizona
  • California
  • Idaho
  • Iowa
  • Kansas
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • North Dakota
  • Oregon
  • South Dakota
  • Utah
  • Washington
  • Wyoming
  Kentucky Medicaid - SKKY0 - Prof Claims SKKY0
  • Kentucky
  Hawaii Medicare - SMHI0 - Prof Claims SMHI0
  • Hawaii
  Texas Medicaid Long Term Care - SKTX1 - Prof Claims SKTX1
  • Texas
  HealthPartners Minnesota - SX009 - Prof Claims SX009
  • Minnesota
  Tricare North - 57106 - Prof Claim 57106
  • Connecticut
  • Delaware
  • District of Columbia
  • Illinois
  • Indiana
  • Kentucky
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • New Hampshire
  • New Jersey
  • New York
  • North Carolina
  • Ohio
  • Pennsylvania
  • Rhode Island
  • Vermont
  • Virginia
  • West Virginia
  • Wyoming
  Nebraska Medicare - SMNE0 - Prof Claim SMNE0
  Keystone Health Plan West - SX056 - Prof Claims SX056
  South Dakota Medicaid - SKSD0 - Prof Claim SKSD0
  • South Dakota
  Independent Health - SX073 - Prof Claim SX073
  Georgia Medicaid - SKGA0 - Professional Claims SKGA0
  • Georgia
  Florida Medicaid - SKFL0 - Prof Claims SKFL0
  • Florida
  South Dakota BCBS - SB889 - Prof Claims SB889
  • South Dakota
  Nebraska Medicaid - SKNE0 - Prof Claim SKNE0
  • Nebraska
  Capital Blue Cross - 23045 - Prof Claims 23045
  Capital Blue Cross Facility - 24705 - Prof Claims 24705
  Nevada Medicare - SMNV0 - Prof Claims SMNV0
  • Nevada
  Wyoming BCBS - SB960 - Prof Claim SB960
  • Wyoming
  Wyoming Medicare - SMWY0 - Prof Claim SMWY0
  • Wyoming
  Washington Medicare - SMWA0 - Prof Claim SMWA0
  • Washington
  Utah Medicare - SMUT0 - Prof Claim SMUT0
  • Utah
  South Dakota Medicare - SMSD0 - Prof Claims SMSD0
  • South Dakota
  Oregon Medicare - SMOR0 - Prof Claim SMOR0
  • Oregon
  North Dakota BCBS - SB820 - Prof Claim SB820
  • North Dakota
  North Dakota Medicare - SMND0 - Prof Claim SMND0
  • North Dakota
  Montana Medicare - SMMT0 - Prof Claim SMMT0
  • Montana
  Iowa Medicaid - SKIA0 - Prof Claim SKIA0
  • Iowa
  Puerto Rico BCBS - SB980 - Prof Claim SB980
  • Puerto Rico
  Michigan BCBS - SB710 - Prof Claim SB710
  • Michigan
  Mississippi Medicaid - SKMS0 - Prof Claims SKMS0
  • Mississippi
  Arkansas BCBS - SB520 - Prof Claims SB520
  • Arkansas
  Rhode Island Medicaid Deactivation- SKRI0 - Prof Claims SKRI0
  Medicare Plus Blue - SX170 - Prof Claim SX170
  Highmark Senior Health - - 95462 - Prof Claim 95462
  West Virginia BCBS - SB941 - Prof Claims SB941
  • West Virginia
  Pennsylvania BCBS - SB865 - Prof Claims SB865
  • Pennsylvania
  Highmark Senior Solution - 95461 - Prof Claim 95461
  Rhode Island Medicaid Enrollment - SKRI0 - Prof Claims SKRI0
  • Rhode Island
  Partners Behavioral Health Management - 52613 - Prof Claim 52613
  Independence Administrators - TA720- Prof Claims TA720
  IBC Personal Choice - SX083 - Prof Claim SX083
  Keystone Health Plan East - SX055 - Prof Claims SX055
  Massachusetts Medicaid - SKMA0 - Pro Claims SKMA0
  • Massachusetts
  Minnesota Medicaid - SKMN0 - Prof Claims SKMN0
  • Minnesota
  Tennessee BCBS - SB890, SB891, SB892- Prof Claims SB890
  • Tennessee
  Illinois Medicaid - SKIL0 - Prof Claims SKIL0
  • Illinois
  Cimarron Medical - 09823 - Prof Claims 09823
  Michigan Medicaid Medical - SKMI0 - Prof Claims SKMI0
  • Michigan
  Washington Medicaid - SKWA0 - Prof Claims SKWA0
  • Washington
  Delaware BCBS - SB570 - Prof Claim SB570
  • Delaware
  Pennsylvania Blue Card Par Point of Service - SX168 - Prof Claim SX168
  • Pennsylvania
  PEHP - SX106 - Prof Claims SX106
  North Carolina Medicaid - SKNC0 - Prof Claim SKNC0
  • North Carolina
  Idaho Blue Cross - SB612 - Prof Claims SB612
  • Idaho
  Vermont Medicaid - SKVT0 - Prof Claims SKVT0
  • Vermont
  New Jersey BCBS - 22099 - Prof Claims 22099
  • New Jersey
  Deseret Mutual - SX105 - Prof Claims SX105
  Montana BCBS Medical - SB751 - Prof Claims SB751
  • Montana
  Louisiana BCBS - 23738 - Prof Claims 23738
  • Louisiana
  University Health Alliance - 99026 - Prof Claims 99026
  Partnership Health Plan of CA CAPHP - SX140 - Prof Claims SX140
  • California
  Alaska Medicaid - SKAK0 - Prof Claims SKAK0
  • Alaska
  Indiana State Dept of Health/CSHCS - 35600 - Prof Claims 35600
  • Indiana
  New York Medicaid - SKNY0 - Prof Claim SKNY0
  • New York
  Tennessee Medicaid - SKTN2 - Prof Claims SKTN2
  • Tennessee
  South Carolina Medicaid - SKSC0 - Prof Claims SKSC0
  • South Carolina