Dental Claims Enrollment Forms

A small subset of payers require additional enrollment tasks be completed prior to accepting claims electronically. Those payers are denoted with a ‘Y’ in the ENROLL column of the Change Healthcare payer list located at Change Healthcare Payer List. If claims are submitted for a payer requiring the additional enrollment tasks prior to the approval being received by Change Healthcare, these claims will be rejected.


All Dental Claims Enrollment Forms

Title Payer ID States
Louisiana Blue Cross Blue Shield 23739 States unavailable for Louisiana Blue Cross Blue Shield
Georgia Medicaid CKGA1 States unavailable for Georgia Medicaid
ALASKA MEDICAID CKAK1 States unavailable for ALASKA MEDICAID
Florida Medicaid CKFL1 States unavailable for Florida Medicaid
Wyoming Blue Cross - CBWY1 Payer ID unavailable for Wyoming Blue Cross - CBWY1 States unavailable for Wyoming Blue Cross - CBWY1
Kentucky Medicaid - Dental Provider Change to Group Practice Enrollment CKKY1 States unavailable for Kentucky Medicaid - Dental Provider Change to Group Practice Enrollment
Texas Medicaid CKTX1 States unavailable for Texas Medicaid
Washington Medicaid CKWA1 States unavailable for Washington Medicaid
New York Medicaid CKNY1 States unavailable for New York Medicaid
Maine Medicaid CKME1 States unavailable for Maine Medicaid
Triple-S CBPR1 States unavailable for Triple-S
South Dakota Blue Cross Blue Shield CBSD1 States unavailable for South Dakota Blue Cross Blue Shield
Idaho Blue Cross CBID1 States unavailable for Idaho Blue Cross
MEDICAL CARD SYSTEM VIA ASSERTUS PRMCS States unavailable for MEDICAL CARD SYSTEM VIA ASSERTUS
New York Medicaid - Trading Partner Agreement CKNY1 States unavailable for New York Medicaid - Trading Partner Agreement
Iowa Medicaid CKIA1 States unavailable for Iowa Medicaid
Minnesota Medicaid CKMN1 States unavailable for Minnesota Medicaid
National Provider Identifier Payer ID unavailable for National Provider Identifier States unavailable for National Provider Identifier
Vermont Medicaid CKVT1 States unavailable for Vermont Medicaid
Washington DC Medicaid CKDC1 States unavailable for Washington DC Medicaid
Oregon Medicaid CKOR1 States unavailable for Oregon Medicaid
Tennesee Blue Cross Blue Shield CBTN1 States unavailable for Tennesee Blue Cross Blue Shield
Utah Medicaid CKUT1 States unavailable for Utah Medicaid
New Mexico Medicaid CKNM1 States unavailable for New Mexico Medicaid
North Dakota Blue Cross Blue Shield CX004 States unavailable for North Dakota Blue Cross Blue Shield
Assertus Payers PRADV States unavailable for Assertus Payers
New Jersey Medicaid - Charity Care CKNJ2 States unavailable for New Jersey Medicaid - Charity Care
Alabama Medicaid CKAL1 States unavailable for Alabama Medicaid
Delaware Medicaid CKDE1 States unavailable for Delaware Medicaid
Idaho Medicaid CKID1 States unavailable for Idaho Medicaid
Alabama Medicaid Tax ID Change CKAL1 States unavailable for Alabama Medicaid Tax ID Change
Wellmark Iowa Blue Dental Blue Cross of South Dakota CBIA2 States unavailable for Wellmark Iowa Blue Dental Blue Cross of South Dakota
Mississippi Medicaid CKMS1 States unavailable for Mississippi Medicaid
Kentucky Medicaid CKKY1 States unavailable for Kentucky Medicaid
Star Plus Value Added CPPSP States unavailable for Star Plus Value Added
Michigan Medicaid CKMI1 States unavailable for Michigan Medicaid
Deseret Mutual Benefit Administrators CX089 States unavailable for Deseret Mutual Benefit Administrators
PEHP (Public Employees Health Program) CX080 States unavailable for PEHP (Public Employees Health Program)
Health Partners CX009 States unavailable for Health Partners
Mississippi Blue Cross Blue Shield CBMS1 States unavailable for Mississippi Blue Cross Blue Shield
New Jersey Medicaid CKNJ1 States unavailable for New Jersey Medicaid
Oregon Medicaid Exhibit C 837D Update Requests CKOR1 States unavailable for Oregon Medicaid Exhibit C 837D Update Requests
Wyoming Medicaid CKWY1 States unavailable for Wyoming Medicaid
Triple Medicare Advantage PRADV States unavailable for Triple Medicare Advantage
Superior Star Pregnant Women CPPSW States unavailable for Superior Star Pregnant Women