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
Nevada Medicaid CKNV1 Nevada
California Medicaid / Medi-Cal 57016 States unavailable for California Medicaid / Medi-Cal
Advantage by Superior CPPSA States unavailable for Advantage by Superior
TRIPLE S CBPR1 States unavailable for TRIPLE S
Wyoming Blue Cross - CBWY1 Payer ID unavailable for Wyoming Blue Cross - CBWY1 States unavailable for Wyoming Blue Cross - CBWY1
Alabama Medicaid Tax ID Change CKAL1 States unavailable for Alabama Medicaid Tax ID Change
Alabama Medicaid CKAL1 States unavailable for Alabama Medicaid
Superior Star Pregnant Women CPPSW States unavailable for Superior Star Pregnant Women
South Dakota Blue Cross Blue Shield CBSD1 States unavailable for South Dakota Blue Cross Blue Shield
PEHP (Public Employees Health Program) CX080 States unavailable for PEHP (Public Employees Health Program)
Oregon Medicaid Exhibit C 837D Update Requests CKOR1 States unavailable for Oregon Medicaid Exhibit C 837D Update Requests
Oregon Medicaid CKOR1 States unavailable for Oregon Medicaid
New York Medicaid - Trading Partner Agreement CKNY1 States unavailable for New York Medicaid - Trading Partner Agreement
New York Medicaid CKNY1 States unavailable for New York Medicaid
Tennessee Blue Cross Blue Shield CBTN1 States unavailable for Tennessee Blue Cross Blue Shield
National Provider Identifier Payer ID unavailable for National Provider Identifier States unavailable for National Provider Identifier
New Mexico Medicaid CKNM1 States unavailable for New Mexico Medicaid
New Jersey Medicaid - Charity Care CKNJ2 States unavailable for New Jersey Medicaid - Charity Care
New Jersey Medicaid CKNJ1 States unavailable for New Jersey Medicaid
Mississippi Medicaid CKMS1 States unavailable for Mississippi Medicaid
Mississippi Blue Cross Blue Shield CBMS1 States unavailable for Mississippi Blue Cross Blue Shield
Louisiana Blue Cross Blue Shield 23739 States unavailable for Louisiana Blue Cross Blue Shield
Minnesota Medicaid CKMN1 States unavailable for Minnesota Medicaid
North Dakota Blue Cross Blue Shield CX004 States unavailable for North Dakota Blue Cross Blue Shield
Michigan Medicaid CKMI1 States unavailable for Michigan Medicaid
MEDICAL CARD SYSTEM VIA ASSERTUS PRMCS States unavailable for MEDICAL CARD SYSTEM VIA ASSERTUS
Kentucky Medicaid - Dental Provider Change to Group Practice Enrollment CKKY1 States unavailable for Kentucky Medicaid - Dental Provider Change to Group Practice Enrollment
Idaho Blue Cross CBID1 States unavailable for Idaho Blue Cross
Idaho Medicaid CKID1 States unavailable for Idaho Medicaid
Kentucky Medicaid CKKY1 States unavailable for Kentucky Medicaid
Iowa Medicaid CKIA1 States unavailable for Iowa Medicaid
Wellmark Iowa Blue Dental Blue Cross of South Dakota CBIA2 States unavailable for Wellmark Iowa Blue Dental Blue Cross of South Dakota
Health Partners CX009 States unavailable for Health Partners
Georgia Medicaid CKGA1 States unavailable for Georgia Medicaid
Delaware Medicaid CKDE1 States unavailable for Delaware Medicaid
Deseret Mutual Benefit Administrators CX089 States unavailable for Deseret Mutual Benefit Administrators
Maine Medicaid CKME1 States unavailable for Maine Medicaid
ALASKA MEDICAID CKAK1 States unavailable for ALASKA MEDICAID
Wyoming Medicaid CKWY1 States unavailable for Wyoming Medicaid
Washington Medicaid CKWA1 States unavailable for Washington Medicaid
Washington DC Medicaid CKDC1 States unavailable for Washington DC Medicaid
Vermont Medicaid CKVT1 States unavailable for Vermont Medicaid
Utah Medicaid CKUT1 States unavailable for Utah Medicaid
Texas Medicaid CKTX1 States unavailable for Texas Medicaid
Triple Medicare Advantage PRADV States unavailable for Triple Medicare Advantage
Star Plus Value Added CPPSP States unavailable for Star Plus Value Added
Florida Medicaid CKFL1 States unavailable for Florida Medicaid
Nebraska Medicaid CKNE1 States unavailable for Nebraska Medicaid
Triple-S CBPR1 States unavailable for Triple-S
North Carolina Medicaid CKNC1 North Carolina