Medical & Hospital Claims Enrollment Forms

​Each provider must be set up in the Change Healthcare system to submit claims. A provider can submit an enrollment form themselves, or instruct their vendor to use our self-service enrollment portal to link you to the payer(s). If your vendor does not have access to the self-service portal, please see our category table below.

Step One: Specific payers require additional EDI enrollment paperwork to be completed for submission of claims. Please check the Change Healthcare Payer List for each payers EDI Enrollment Requirements.
Step Two: If EDI paperwork is required by a payer, you must receive an approval from the payer prior to submitting claims. Claims submitted without prior approval will be rejected.

***NOTE: If hard-copy forms are submitted by a vendor that has on-line access to the Change Healthcare portal, the hard-copy forms will be rejected.

Commonly Used Claims Enrollment Forms


Claims Payer Enrollment Forms

Title Payer ID States
Contra Costa Health Plan - CCHP - Inst Claim CCHP States unavailable for Contra Costa Health Plan - CCHP - Inst Claim
Nebraska Medicaid - 12K19 - Inst Claims 12K19 Nebraska
Highmark Senior Solution - 95461 - Inst Claims 95461 West Virginia
Blue Cross Blue Shield of Tennessee - 12B53 - INST CLAIMS 12B53 Tennessee
HIGHMARK SENIOR HEALTH - 95462 - INST CLAIM 95462 States unavailable for HIGHMARK SENIOR HEALTH - 95462 - INST CLAIM
VIRGINIA PREMIER ELITE PLUS (MLTSS) - MLTSS - INST CLAIMS MLTSS Virginia
CALIFORNIA MEDI-CAL - 57016 - INST CLAIM 57016 California
WA State Dept of Labor and Industry - SX063 - INST Claims SX063 Washington
Tricare East - 68299 - Institutional Claims 68299 Alabama , Arkansas , Connecticut , Delaware , Florida , Georgia , Illinois , Indiana , Kentucky , Louisiana , Maine , Maryland , Massachusetts , Michigan , Mississippi , New Hampshire , New Jersey , New York , North Carolina , Ohio , Oklahoma , Pennsylvania , Rhode Island , South Carolina , Tennessee , Texas , Vermont , Virginia , West Virginia , Wisconsin
Deseret Mutual - 12X35 - INST Claims 12X35 States unavailable for Deseret Mutual - 12X35 - INST Claims
GUILDNET - GLDNT - INST CLAIMS GLDNT States unavailable for GUILDNET - GLDNT - INST CLAIMS
ALOHACARE ADVANTAGE - ALOHA - INST CLAIMS ALOHA Hawaii
Wyoming BC - 12B30 - Inst Claim 12B30 Wyoming
Hawaii BCBS - 12B62 - Inst Claims 12B62 States unavailable for Hawaii BCBS - 12B62 - Inst Claims
Colorado Medicaid - 12K03 - Inst Claims 12K03 Colorado
South Dakota Medicare - 12M83 - Inst Claim 12M83 South Dakota
New Jersey Medicare - 12005 - Inst Claim 12005 New Jersey
Vermont Medicare - 12M26 - Inst Claims 12M26 Vermont
TriWest VAPC3 Region 3 - 55912 - Inst Claims 55912 States unavailable for TriWest VAPC3 Region 3 - 55912 - Inst Claims
Legacy Medicare WPS J5 - 52280 - Inst Claims 52280 Iowa , Kansas , Michigan , Missouri , Nebraska
AK & ID Medicare - 12M07 - Inst Claim 12M07 Alaska , Idaho
J1 MUTUAL of OMAHA CA, HI, NV - 12M64 - INST CLAIM 12M64 California , Hawaii , Nevada
RHHI Home Health Region V - Service Area 7 - 12HHA - Inst Claims 12HHA States unavailable for RHHI Home Health Region V - Service Area 7 - 12HHA - Inst Claims
TriWest VAPC3 Region 6 - 55917 - Inst Claims 55917 States unavailable for TriWest VAPC3 Region 6 - 55917 - Inst Claims
Alliance Behavioral Healthcare - 23071- Institutional Claims 23071 States unavailable for Alliance Behavioral Healthcare - 23071- Institutional Claims
Tricare West - 12C01 - Inst Claims 12C01 States unavailable for Tricare West - 12C01 - Inst Claims
Massachusetts Medicaid - 12K14 - Inst Claims 12K14 Massachusetts
New Mexico Medicare - 12M22 - Inst Claim 12M22 New Mexico
FTP TSO Request Form Payer ID unavailable for FTP TSO Request Form States unavailable for FTP TSO Request Form
Maryland Medicare - 12010 - Inst Claim 12010 Maryland
DC Medicare - 12M63 - Inst Claims 12M63 District of Columbia
Delaware Medicare - 12M76 - Inst Claims 12M76 Delaware
Pennsylvania Medicare - 12M60 - Inst Claim 12M60 Pennsylvania
Mississippi BCBS & Teachers Blue - 12B17_12B82 - 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
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
Louisiana Medicaid - 12K12 - Inst Claim 12K12 Louisiana
Tennessee Medicare - 12M53 - Inst Claims 12M53 Tennessee
Georgia Medicare - 12M05 - Inst Claim 12M05 Georgia
Alabama Medicare - 12M01 - Inst Claim 12M01 Alabama
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
Virginia Medicare - 12004 – Inst Claims 12004 Virginia
Wisconsin Medicare & FQHC - 12M29 - Inst Claims 12M29 Wisconsin
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
Massachusetts Medicare - 12M14 - Inst Claims 12M14 Massachusetts
Amerihealth PPO NJ - 12X28 - Inst Claims 12X28 New Jersey
WPS Health Insurance - 12X29 - Inst Claim 12X29 States unavailable for WPS Health Insurance - 12X29 - Inst Claim
PEHP - 12X36 - Inst Claims 12X36 States unavailable for PEHP - 12X36 - Inst Claims
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
Kentucky Medicare - 12M11 - Inst Claim 12M11 Kentucky
Value Options - Commercial - 12X56 - Inst Claim 12X56 States unavailable for Value Options - Commercial - 12X56 - Inst Claim
Value Options Pennsylvania - 12K1A - Inst Claims 12K1A States unavailable for Value Options Pennsylvania - 12K1A - Inst Claims
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
Michigan Medicare - 12M18 - Inst Claim 12M18 Michigan
Indiana Medicare - 12M09 - Inst Claims 12M09 Indiana
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
IBC Personal Choice - 12X26 - Inst Claims 12X26 States unavailable for IBC Personal Choice - 12X26 - Inst Claims
Keystone Health Plan East /IBC - 12X25 - Inst Claims 12X25 States unavailable for Keystone Health Plan East /IBC - 12X25 - Inst Claims
Illinois Medicaid - 12K08 - Inst Claims 12K08 Illinois
South Dakota Medicaid - 12K36 - Inst Claims 12K36 South Dakota
Georgia Medicaid - 12K05 - Inst Claims 12K05 Georgia
Florida Medicaid - 12K34 - Inst Claims 12K34 Florida
Iowa BCBS - 12B10 - Inst Claims 12B10 Iowa
Capital Blue Cross - 12B61 - Inst Claim 12B61 States unavailable for Capital Blue Cross - 12B61 - Inst Claim
HealthPartners of Minnesota - 12X51 - Inst Claims 12X51 States unavailable for HealthPartners of Minnesota - 12X51 - Inst Claims
Alaska Medicaid - 12K86 - Inst Claims 12K86 Alaska
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
Mississippi Medicaid - 12K17 - Inst Claims 12K17 Mississippi
Arkansas Blue Cross - 12021 - Inst Claims 12021 Arkansas
Tennessee Medicaid - 12K46 - Inst Claims 12K46 Tennessee
West Virginia Blue Cross - 12B28 - Inst Claims 12B28 West Virginia
Virginia Premier - 12K83 - Inst Claims 12K83 Virginia
Washington Medicaid Hospital - 12K27 - Inst Claims 12K27 Washington
Maryland Behavioral Health - 22322 - Inst Claims 22322 Maryland
Delaware BC - 12B76 - Inst Claim 12B76 Delaware
Independent Health - 12X01 - Inst Claim 12X01 States unavailable for Independent Health - 12X01 - Inst Claim
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 - Inst Claims 12B45 Tennessee
Louisiana BCBS - 12B12 - Inst Claims 12B12 Louisiana
Minnesota Medicaid - 12K16 - Inst Claims 12K16 Minnesota
Partnership Health Plan of CA - 12M81 - Inst Claims 12M81 California
Nevada Medicaid - 12K20 - Inst Claims 12K20 Nevada
MISSISSIPPI BLUE CROSS - 12B82 - INST CLAIMS 12B82 Mississippi
TriWest VAPC3 Region 5B - 55916 - Inst Claims 55916 States unavailable for TriWest VAPC3 Region 5B - 55916 - Inst Claims
TriWest VAPC3 Region 5A - 55915 - Inst Claims 55915 States unavailable for TriWest VAPC3 Region 5A - 55915 - Inst Claims
Partners Behavioral Health Management - 52613 - Inst Claim 52613 States unavailable for Partners Behavioral Health Management - 52613 - Inst Claim
Security Health Plan - 39045 - Inst Claims 39045 States unavailable for Security Health Plan - 39045 - Inst Claims
Maine Medicaid - 12K13 - Inst Claim 12K13 Maine
Connecticut Medicare - 12M04 - Inst Claims 12M04 Connecticut
Minnesota Medicare - 12M16 - Inst Claims 12M16 Minnesota
North Dakota Medicare - 12M82 - Inst Claim 12M82 North Dakota
Puerto Rico Medicare - 12M49 - Inst Claims 12M49 Puerto Rico
US Virgin Islands Medicare - 12M52 - Inst Claim 12M52 Virgin Islands
Amerihealth Administrators - 54763 - Inst Claims 54763 States unavailable for Amerihealth Administrators - 54763 - Inst Claims
New Jersey Medicaid - 12006 - Inst Claims 12006 New Jersey
Florida Medicare - 12M34 - Inst Claim 12M34 Florida
Tricare Overseas - 12X46 - Inst Claims 12X46 States unavailable for Tricare Overseas - 12X46 - Inst Claims
South Dakota BCBS - 12B33 - Inst Claims 12B33 South Dakota
Maryland Medicaid -- 12007 - Inst Claims 12007 Maryland
Maine Medicare - 12M13 - Inst Claims 12M13 Maine
Utah Medicaid - 12K42 - Inst Claims 12K42 Utah
Wyoming Medicare - 12M30 - Inst Claim 12M30 Wyoming
Washington Medicare - 12M45 - Inst Claim 12M45 Washington
New Hampshire Medicare - 12M21 - Inst Claims 12M21 New Hampshire
Ohio Medicare – 12M24 – Inst Claims 12M24 Ohio
J12 Highmark for DC, DE, MD, NJ, and PA – J12901 - Legacy - 12M99 - Inst Claim 12M99 Delaware , District of Columbia , Maryland , New Jersey , Pennsylvania
Value Optiosn (TX NorthStar) - 99297 - Inst Claims 99297 Texas
Pennsylvania BCBS Central Highmark - 12B81 - Inst Claims 12B81 Pennsylvania
West Virginia Medicare - 12M28 - Inst Claims 12M28 West Virginia
Arizona Medicare - 12M02 - Inst Claim 12M02 Arizona
Penn Behavioral Health - 53226 - Inst Claims 53226 States unavailable for Penn Behavioral Health - 53226 - Inst Claims
Hawaii Medicaid Hospital - 12K62 - Inst Claims 12K62 Hawaii
New York Medicare - 12M35 - Inst Claims 12M35 New York
ValueOptions/MBHP (MA Behavioral Health Partnership - 43307 - Inst Claims 43307 Massachusetts
Pennsylvania Western BC - 12B60 - Inst Claims 12B60 Pennsylvania
Claims Provider Setup Form Payer ID unavailable for Claims Provider Setup Form States unavailable for Claims Provider Setup Form
Carolina Crescent - 12K85 - Inst Claims 12K85 States unavailable for Carolina Crescent - 12K85 - Inst Claims
Health Adv/US Able/First Pyramid Life/Arkansas Blue Cross - 12049 - Inst Claims 12049 Arkansas
Michigan Medicaid Hospital - 12K37 - Inst Claims 12K37 Michigan
Rhode Island Medicare - 12M74 - Inst Claims 12M74 Rhode Island
Wyoming Medicaid - 12K30 - Inst Claim 12K30 Wyoming
Idaho True Blue - 12B84 - Inst Claims 12B84 Idaho
Montana Medicare - 12M77 - Inst Claim 12M77 Montana
Iowa Medicaid - 12K10 - Inst Claim 12K10 Iowa
North Dakota BC - 12B78 - Inst Claim 12B78 North Dakota
CA Home Health & Hospice - 12M98 Inst Claims 12M98 California
Utah Medicare - 12M84 - Inst Claim 12M84 Utah
Oregon Medicare - 12M41 - Inst Claim 12M41 Oregon
Legacy Part A - CA - HI- NV - 12M65 - Inst Claim 12M65 California , Hawaii , Nevada
Tricare for Life - 12X43 - Inst Claim 12X43 States unavailable for Tricare for Life - 12X43 - Inst Claim
Illinois Medicare - 12M08 - Inst Claims 12M08 Illinois
Rhode Island Medicaid Enrollment- 12K74 - Inst Claims 12K74 Rhode Island
New York State Medicaid - 12K35 - Inst Claims 12K35 New York
Montana BCBS Hospital - 12B77 - Inst Claims 12B77 Montana
Health Safety Network / MASS. Health Medicaid- 12K48 - Inst Claims 12K48 Massachusetts