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
Louisiana Medicaid - Ambulance claims - SKLA2 - PROF CLAIMS SKLA2 States unavailable for Louisiana Medicaid - Ambulance claims - SKLA2 - PROF CLAIMS
Louisiana Medicaid - DME Claims - SKLA1 - PROF CLAIMS SKLA1 Louisiana
Puerto Rico BCBS - SB980 - Prof Claim SB980 Puerto Rico
Wyoming BCBS - SB960 - Prof Claim SB960 Wyoming
Oklahoma Medicare - SMOK0 - Prof Claim SMOK0 Oklahoma
Mississippi Medicare – SMMS0 – Prof Claim SMMS0 Mississippi
Massachusetts Medicare - SMMA0 - Prof Claims SMMA0 Massachusetts
Indiana State Dept of Health/CSHCS - 35600 - Prof Claims 35600 Indiana
HealthPlus of Michigan - 38216 - Prof Claims 38216 Michigan
Florida Medicaid - SKFL0 - Prof Claims SKFL0 Florida
Colorado Medicaid - SKCO0 - Prof Claims SKCO0 Colorado
District of Columbia Medicaid - SKDC0 - Prof Claim SKDC0 District of Columbia
South Carolina Medicare - SMSC0 - Prof Claims SMSC0 South Carolina
Maryland Medicare - SMMD0 - Prof Claim SMMD0 Maryland
District of Columbia Medicare - SMDC0 - Prof Claim SMDC0 District of Columbia
Delaware Medicare - SMDE0 - Prof Claim SMDE0 Delaware
Virginia Premier Health Plan - 54176 - Prof Claims 54176 Virginia
Mississippi BCBS - SB730 - Prof Claims SB730 Mississippi
Blue Care Network - SB711 - Prof Claims SB711 Michigan
New Jersey Medicare - SMNJ0 - Prof Claim SMNJ0 New Jersey
Pennsylvania Medicare – SMPA0 – Prof Claim SMPA0 Pennsylvania
Louisiana Medicaid - SKLA0 - Prof Claims SKLA0 Louisiana
Nevada Medicaid - SKNV0 - Prof Claims SKNV0 Nevada
Puerto Rico Medicare - SMPR0 - Prof Claim SMPR0 Puerto Rico
Virgin Island Medicare - SMVI0 - Prof Claims SMVI0 Virgin Islands
Ohio Medicare - SMOH0 - Prof Claims SMOHO Ohio
Kentucky Medicare - SMKY0 - Prof Claims SMKY0 Kentucky
Kentucky Medicaid - SKKY0 - Prof Claims SKKY0 Kentucky
HealthPartners Minnesota - SX009 - Prof Claims SX009 Minnesota
South Dakota BCBS - SB889 - Prof Claims SB889 South Dakota
Capital Blue Cross - 23045 - Prof Claims 23045 States unavailable for Capital Blue Cross - 23045 - Prof Claims
Capital Blue Cross Facility - 24705 - Prof Claims 24705 States unavailable for Capital Blue Cross Facility - 24705 - Prof Claims
Georgia Medicaid - SKGA0 - Professional Claims SKGA0 Georgia
Arkansas BCBS - SB520 - Prof Claims SB520 Arkansas
Michigan BCBS - SB710 - Prof Claim SB710 Michigan
Medicare Plus Blue - SX170 - Prof Claim SX170 States unavailable for Medicare Plus Blue - SX170 - Prof Claim
Idaho Blue Cross - SB612 - Prof Claims SB612 Idaho
PEHP - SX106 - Prof Claims SX106 States unavailable for PEHP - SX106 - Prof Claims
University Health Alliance - 99026 - Prof Claims 99026 States unavailable for University Health Alliance - 99026 - Prof Claims
Louisiana BCBS - 23738 - Prof Claims 23738 Louisiana
Tricare East - 68299 - Professional 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
TriWest VAPC3 Region 5B - 55916 - Prof Claims 55916 States unavailable for TriWest VAPC3 Region 5B - 55916 - Prof Claims
TriWest VAPC3 Region 6 - 55917 - Prof Claims 55917 States unavailable for TriWest VAPC3 Region 6 - 55917 - Prof Claims
TriWest VAPC3 Region 5A - 55915 - Prof Claims 55915 States unavailable for TriWest VAPC3 Region 5A - 55915 - Prof Claims
TriWest VAPC3 Region 3 - 55912 - Prof Claims 55912 States unavailable for TriWest VAPC3 Region 3 - 55912 - Prof Claims
GUILDNET - GLDNT - PROF CLAIMS GLDNT States unavailable for GUILDNET - GLDNT - PROF CLAIMS
Aloha Advantage - ALOHA - Prof Claims ALOHA Hawaii
Alliance Behavioral Healthcare - 23071- Professional Claims 23071 States unavailable for Alliance Behavioral Healthcare - 23071- Professional Claims
ATRIO FKA MARION POLK - MPCHA - PROF CLAIMS MPCHA Oregon
Arizona Medicare - SMAZ0 - Prof Claim SMAZ0 Arizona
FTP TSO Request Form Payer ID unavailable for FTP TSO Request Form States unavailable for FTP TSO Request Form
DMERC Region D - SDMED - Prof Clams SDMED Arizona , California , Idaho , Iowa , Kansas , Missouri , Montana , Nebraska , Nevada , North Dakota , Oregon , South Dakota , Utah , Washington , Wyoming
WPS Commercial - SX022 - Prof Claims SX022 States unavailable for WPS Commercial - SX022 - Prof Claims
North Carolina Medicare - SMNC0 - Prof Claims SMNC0 North Carolina
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
Health Services Management -41150 - Prof Claims 41150 States unavailable for Health Services Management -41150 - Prof Claims
Pennsylvania Blue Card Par Point of Service - SX168 - Prof Claim SX168 Pennsylvania
Hawaii Medicaid Waviers - 77059 - Prof Claims 77059 Hawaii
Hawaii BCBS - SB971 - Prof Claims SB971 Hawaii
WA State Dept of Labor and Industry - SX063 - Prof Claims SX063 Washington
South Dakota Medicare - SMSD0 - Prof Claims SMSD0 South Dakota
Amerihealth Delaware Non HMO - SX074 - Prof Claims SX074 States unavailable for Amerihealth Delaware Non HMO - SX074 - Prof Claims
Texas Medicaid Long Term Care - SKTX1 - Prof Claims SKTX1 Texas
Delaware BCBS - SB570 - Prof Claim SB570 Delaware
Iowa BCBS - SB640 - Prof Claims SB640 Iowa
California Medicare - SMCA1 - Prof Claims SMCA1 California
Illinois Medicare - SMIL0 - Prof Claim SMIL0 Illinois
Independence Administrators - TA720- Prof Claims TA720 States unavailable for Independence Administrators - TA720- Prof Claims
Vermont Medicaid - SKVT0 - Prof Claims SKVT0 Vermont
Pensylvania BC - SX079 - Prof Claims SX079 Pennsylvania
Oregon Medicaid - SKOR0 - Prof Claim SKOR0 Oregon
California Medi-Cal Vision - SKCA1 - Prof Claim SKCA1 California
Nebraska Medicaid - SKNE0 - Prof Claim SKNE0 Nebraska
Washington Medicare - SMWA0 - Prof Claim SMWA0 Washington
Florida Medicare - SMFL0 - Prof Claim SMFL0 Florida
DMERC Region A - SDMEA - Prof Claims SDMEA Connecticut , Maine , Massachusetts , New Hampshire , New Jersey , New York , Pennsylvania , Rhode Island , Vermont
Maryland Behavioral Health - SX069 - Prof Claims SX069 Maryland
Independent Health - SX073 - Prof Claim SX073 States unavailable for Independent Health - SX073 - Prof Claim
Amerihealth Administrators - 54763 - Prof Claims 54763 States unavailable for Amerihealth Administrators - 54763 - Prof Claims
Amerihealth New Jersey Non HMO - SX075 - Prof Claims SX075 New Jersey
North Carolina Medicaid - SKNC0 - Prof Claim SKNC0 North Carolina
Pennsylvania BCBS - SB865 - Prof Claims SB865 Pennsylvania
New York Medicaid - SKNY0 - Prof Claim SKNY0 New York
Vermont Medicare - SMVT0 - Prof Claims SMVT0 Vermont
Alaska Medicare - SMAK0 - Prof Claim SMAK0 Alaska
Hawaii Medicare - SMHI0 - Prof Claims SMHI0 Hawaii
Colorado Medicare – SMCO0 – Prof Claim SMCO0 Colorado
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
Maryland Medicaid - SKMD0 - Prof Claims SKMD0 Maryland
Value Options - SX173 - Prof Claims SX173 States unavailable for Value Options - SX173 - Prof Claims
Illinois Medicaid - SKIL0 - Prof Claims SKIL0 Illinois
Montana Medicare - SMMT0 - Prof Claim SMMT0 Montana
Partners Behavioral Health Management - 52613 - Prof Claim 52613 States unavailable for Partners Behavioral Health Management - 52613 - Prof Claim
New Mexico Medicare - SMNM0 - Prof Claims SMNM0 New Mexico
Missouri Medicare - SMMO0 - Prof Claim SMMO0 Missouri
Indiana Medicare - SMIN0 - Prof Claim SMIN0 Indiana
Delaware Medicaid - SKDE0 - Prof Claims SKDE0 Delaware
Rhode Island Medicaid Deactivation- SKRI0 - Prof Claims SKRI0 States unavailable for Rhode Island Medicaid Deactivation- SKRI0 - Prof Claims
Minnesota Medicaid - SKMN0 - Prof Claims SKMN0 Minnesota
Security Health Plan - 39045 - Prof Claims 39045 States unavailable for Security Health Plan - 39045 - Prof Claims
Virginia Medicare - SMVA0 - Prof Claims SMVA0 Virginia
IBC Personal Choice - SX083 - Prof Claim SX083 States unavailable for IBC Personal Choice - SX083 - Prof Claim
Value Options/ MBHP (MA Behavioral Health Partnership) - 43307 - Prof Claims 43307 States unavailable for Value Options/ MBHP (MA Behavioral Health Partnership) - 43307 - Prof Claims
Claims Provider Setup Form Payer ID unavailable for Claims Provider Setup Form States unavailable for Claims Provider Setup Form
Highmark Senior Health - - 95462 - Prof Claim 95462 States unavailable for Highmark Senior Health - - 95462 - Prof Claim
Tennessee BCBS - SB890, SB891, SB892- Prof Claims SB890 Tennessee
Railroad Medicare - SRRGA - Prof Claims SRRGA ~All States
Tricare for Life - SX176 - Prof Claim SX176 States unavailable for Tricare for Life - SX176 - Prof Claim
Texas Medicare - SMTX0 - Prof Claim SMTX0 Texas
Tennessee Medicaid - SKTN2 - Prof Claims SKTN2 Tennessee
Blue Cross Blue Shield Mississippi State and Teacher Employees - SB731 - Prof Claims SB731 Mississippi
New Jersey BCBS - 22099 - Prof Claims 22099 New Jersey
Wisconsin Medicare - SMWI0 - Prof Claim SMWI0 Wisconsin
Penn Behavioral Health - 53226 - Prof Claims 53226 States unavailable for Penn Behavioral Health - 53226 - Prof Claims
California Medicaid - SKCA0 - Prof Claims SKCA0 California
Iowa Medicaid - SKIA0 - Prof Claim SKIA0 Iowa
Amerihealth HMO New Jersey and Delaware - 23037 - Prof Claims 23037 Delaware , New Jersey
Louisiana Medicare - SMLA0 - Prof Claims SMLA0 Louisiana
Maine Medicaid - SKME0 - Prof Claim SKME0 Maine
Maine Medicare - SMME0 - Prof Claims SMME0 Maine
New Hampshire Medicare - SMNH0 - Prof Claims SMNH0 New Hampshire
Oregon Medicare - SMOR0 - Prof Claim SMOR0 Oregon
Utah Medicare - SMUT0 - Prof Claim SMUT0 Utah
Tricare Overseas - SX163 - Prof Claims SX163 States unavailable for Tricare Overseas - SX163 - Prof Claims
Minnesota Medicare - SMMN0 - Prof Claim SMMN0 Minnesota
Deseret Mutual - SX105 - Prof Claims SX105 States unavailable for Deseret Mutual - SX105 - Prof Claims
Keystone Health Plan West - SX056 - Prof Claims SX056 States unavailable for Keystone Health Plan West - SX056 - Prof Claims
North Dakota Medicare - SMND0 - Prof Claim SMND0 North Dakota
West Virginia BCBS - SB941 - Prof Claims SB941 West Virginia
Michigan Medicare - SMMI0 - Prof Claim SMMI0 Michigan
Kansas Medicare - SMKS0 - Prof Claim SMKS0 Kansas
Arkansas Medicare - SMAR0 - Prof Claim SMAR0 Arkansas
South Dakota Medicaid - SKSD0 - Prof Claim SKSD0 South Dakota
Connecticut Medicare - SMCT0 - Prof Claim SMCT0 Connecticut
Montana BCBS Medical - SB751 - Prof Claims SB751 Montana
Massachusetts Medicaid - SKMA0 - Pro Claims SKMA0 Massachusetts
Nebraska Medicare - SMNE0 - Prof Claim SMNE0 States unavailable for Nebraska Medicare - SMNE0 - Prof Claim
New York Medicare GHI - SMNY2 - Prof Claim SMNY2 New York
Wyoming Medicare - SMWY0 - Prof Claim SMWY0 Wyoming
Mississippi Medicaid - SKMS0 - Prof Claims SKMS0 Mississippi
Partnership Health Plan of CA CAPHP - SX140 - Prof Claims SX140 California
West Virginia Medicare - SMWV0 - Prof Claims SMWV0 West Virginia
DMERC Region B - SDMEB - Prof Claims SDMEB Illinois , Indiana , Michigan , Minnesota , Ohio , Virginia , West Virginia , Wisconsin
Rhode Island Medicare - SMRI0 - Prof Claims SMRI0 Rhode Island
Washington Medicaid - SKWA0 - Prof Claims SKWA0 Washington
Tennessee Medicare - SMTN0 - Prof Claim SMTN0 Tennessee
Iowa Medicare - SMIA0 - Prof Claim SMIA0 Iowa
California Medicare South - SMCA2 - Prof Claims SMCA2 California
New York Medicare Upstate - Western - SMNY1 - Prof Claim SMNY1 New York
North Dakota BCBS - SB820 - Prof Claim SB820 North Dakota
Rhode Island Medicaid Enrollment - SKRI0 - Prof Claims SKRI0 Rhode Island
Alabama Medicare - SMAL0 - Prof Claim SMAL0 Alabama
South Carolina Medicaid - SKSC0 - Prof Claims SKSC0 South Carolina
Highmark Senior Solution - 95461 - Prof Claim 95461 States unavailable for Highmark Senior Solution - 95461 - Prof Claim
Michigan Medicaid Medical - SKMI0 - Prof Claims SKMI0 Michigan
Hawaii Medicaid - SKHI0 - Prof Claims SKHI0 Hawaii
Georgia Medicare - SMGA0 - Prof Claim SMGA0 Georgia
Alaska Medicaid - SKAK0 - Prof Claims SKAK0 Alaska
Keystone Health Plan East - SX055 - Prof Claims SX055 States unavailable for Keystone Health Plan East - SX055 - Prof Claims
New York Medicare Empire - SMNY0 - Prof Claim SMNY0 New York
New Jersey Medicaid - SKNJ0 - Prof Claims SKNJ0 New Jersey
Utah Medicaid - SKUT0 - Prof Claims SKUT0 Utah
Idaho Medicare - SMID0 - Prof Claims SMID0 Idaho
Wyoming Medicaid - SKWY0 - Prof Claims SKWY0 Wyoming
Nevada Medicare - SMNV0 - Prof Claims SMNV0 Nevada
Cimarron Medical - 09823 - Prof Claims 09823 States unavailable for Cimarron Medical - 09823 - Prof Claims