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.


Claims Payer Enrollment Forms

Title Payer ID States
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
CONTRA COSTA HEALTH PLAN - CNTRA - PROF CLAIMS CNTRA States unavailable for CONTRA COSTA HEALTH PLAN - CNTRA - PROF CLAIMS
NEW YORK HOTEL FUND - 7707C - PROF CLAIMS 7707C New York
Pennsylvania Blue Card Par Point of Service - SX168 - Prof Claim SX168 Pennsylvania
Highmark Senior Solution - 95461 - Prof Claim 95461 States unavailable for Highmark Senior Solution - 95461 - Prof Claim
Nebraska Medicaid - SKNE0 - Prof Claim SKNE0 Nebraska
Tricare Overseas - SX163 - Prof Claims SX163 States unavailable for Tricare Overseas - SX163 - Prof Claims
Blue Cross Blue Shield Tennessee (Chattanooga HMO) - SB891 - PROF CLAIMS SB891 Tennessee
Tennessee BCBS (Memphis) - SB892 - PROF CLAIMS SB892 Tennessee
HUMAN ARC - 34818 - PROF Claims 34818 States unavailable for HUMAN ARC - 34818 - PROF Claims
EYEMED VISION CARE - 85431 - PROF CLAIMS 85431 States unavailable for EYEMED VISION CARE - 85431 - PROF CLAIMS
VIRGINIA PREMIER ELITE PLUS (MLTSS) - MLTSS - PROF CLAIMS MLTSS Virginia
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
Georgia Medicare - SMGA0 - Prof Claim SMGA0 Georgia
Tennessee Blue Cross Blue Sheild - SB890 - Prof Claims SB890 Tennessee
Alabama Medicare - SMAL0 - Prof Claim SMAL0 Alabama
Tennessee Medicare - SMTN0 - Prof Claim SMTN0 Tennessee
Vermont Medicaid - SKVT0 - Prof Claims SKVT0 Vermont
Triple-S - SB980 - Prof Claim SB980 Puerto Rico
Deseret Mutual - SX105 - Prof Claims SX105 States unavailable for Deseret Mutual - SX105 - Prof Claims
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
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
TriWest VAPC3 Region 6 - 55917 - Prof Claims 55917 States unavailable for TriWest VAPC3 Region 6 - 55917 - Prof Claims
Aloha Advantage - ALOHA - Prof Claims ALOHA Hawaii
FTP TSO Request Form Payer ID unavailable for FTP TSO Request Form States unavailable for FTP TSO Request 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
District of Columbia Medicaid - SKDC0 - Prof Claim SKDC0 District of Columbia
Louisiana Medicare - SMLA0 - Prof Claims SMLA0 Louisiana
Texas Medicare - SMTX0 - Prof Claim SMTX0 Texas
Colorado Medicare – SMCO0 – Prof Claim SMCO0 Colorado
Arkansas Medicare - SMAR0 - Prof Claim SMAR0 Arkansas
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
Blue Cross Blue Shield Mississippi State and Teacher Employees - SB731 - Prof Claims SB731 Mississippi
Mississippi BCBS - SB730 - Prof Claims SB730 Mississippi
Virginia Premier Health Plan - 54176 - Prof Claims 54176 Virginia
Penn Behavioral Health - 53226 - Prof Claims 53226 States unavailable for Penn Behavioral Health - 53226 - Prof Claims
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 States unavailable for Amerihealth Delaware Non HMO - SX074 - Prof Claims
Oregon Medicaid - SKOR0 - Prof Claim SKOR0 Oregon
Louisiana Medicaid - SKLA0 - Prof Claims SKLA0 Louisiana
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
WA State Dept of Labor and Industry - SX063 - Prof Claims SX063 Washington
New York Medicare Upstate - Western - SMNY1 - Prof Claim SMNY1 New York
Connecticut Medicare - SMCT0 - Prof Claim SMCT0 Connecticut
Illinois Medicare - SMIL0 - Prof Claim SMIL0 Illinois
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
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 States unavailable for WPS Commercial - SX022 - Prof Claims
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
Inter-County Health Plan - SX079 - Prof Claims SX079 Pennsylvania
Ohio Medicare - SMOH0 - Prof Claims SMOHO Ohio
Kentucky Medicare - SMKY0 - Prof Claims SMKY0 Kentucky
Maryland Behavioral Health - SX069 - Prof Claims SX069 Maryland
Hawaii Medicaid Waivers - 77059 - Prof Claims 77059 Hawaii
California Medicare South - SMCA2 - Prof Claims SMCA2 California
California Medicare - SMCA1 - Prof Claims SMCA1 California
Kentucky Medicaid - SKKY0 - Prof Claims SKKY0 Kentucky
HealthPartners Minnesota - SX009 - Prof Claims SX009 Minnesota
Nebraska Medicare - SMNE0 - Prof Claim SMNE0 States unavailable for Nebraska Medicare - SMNE0 - Prof Claim
South Dakota Medicaid - SKSD0 - Prof Claim SKSD0 South Dakota
Georgia Medicaid - SKGA0 - Professional Claims SKGA0 Georgia
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
South Dakota Medicare - SMSD0 - Prof Claims SMSD0 South Dakota
Montana Medicare - SMMT0 - Prof Claim SMMT0 Montana
Michigan BCBS - SB710 - Prof Claim SB710 Michigan
Mississippi Medicaid - SKMS0 - Prof Claims SKMS0 Mississippi
Arkansas BCBS - SB520 - Prof Claims SB520 Arkansas
Medicare Plus Blue - SX170 - Prof Claim SX170 States unavailable for Medicare Plus Blue - SX170 - Prof Claim
West Virginia BCBS - SB941 - Prof Claims SB941 West Virginia
Pennsylvania BCBS - SB865 - Prof Claims SB865 Pennsylvania
Rhode Island Medicaid Enrollment - SKRI0 - Prof Claims SKRI0 Rhode Island
Independence Administrators - TA720- Prof Claims TA720 States unavailable for Independence Administrators - TA720- Prof Claims
IBC Personal Choice - SX083 - Prof Claim SX083 States unavailable for IBC Personal Choice - SX083 - Prof Claim
Keystone Health Plan East - SX055 - Prof Claims SX055 States unavailable for Keystone Health Plan East - SX055 - Prof Claims
Massachusetts Medicaid - SKMA0 - Pro Claims SKMA0 Massachusetts
Minnesota Medicaid - SKMN0 - Prof Claims SKMN0 Minnesota
Delaware BCBS - SB570 - Prof Claim SB570 Delaware
PEHP - SX106 - Prof Claims SX106 States unavailable for PEHP - SX106 - Prof Claims
North Carolina Medicaid - SKNC0 - Prof Claim SKNC0 North Carolina
Idaho Blue Cross - SB612 - Prof Claims SB612 Idaho
Louisiana BCBS - 23738 - Prof Claims 23738 Louisiana
University Health Alliance - 99026 - Prof Claims 99026 States unavailable for University Health Alliance - 99026 - Prof Claims
Partnership Health Plan of CA CAPHP - SX140 - Prof Claims SX140 California
Alaska Medicaid - SKAK0 - Prof Claims SKAK0 Alaska
Tennessee Medicaid - SKTN2 - Prof Claims SKTN2 Tennessee
TriWest VAPC3 Region 5B - 55916 - Prof Claims 55916 States unavailable for TriWest VAPC3 Region 5B - 55916 - 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
Alliance Behavioral Healthcare - 23071- Professional Claims 23071 States unavailable for Alliance Behavioral Healthcare - 23071- Professional Claims
Arizona Medicare - SMAZ0 - Prof Claim SMAZ0 Arizona
Health Services Management -41150 - Prof Claims 41150 States unavailable for Health Services Management -41150 - Prof Claims
Hawaii BCBS - SB971 - Prof Claims SB971 Hawaii
Texas Medicaid Long Term Care - SKTX1 - Prof Claims SKTX1 Texas
Iowa BCBS - SB640 - Prof Claims SB640 Iowa
Florida Medicare - SMFL0 - Prof Claim SMFL0 Florida
Washington Medicare - SMWA0 - Prof Claim SMWA0 Washington
Amerihealth Administrators - 54763 - Prof Claims 54763 States unavailable for Amerihealth Administrators - 54763 - Prof Claims
Independent Health - SX073 - Prof Claim SX073 States unavailable for Independent Health - SX073 - Prof Claim
New York Medicaid - SKNY0 - Prof Claim SKNY0 New York
Alaska Medicare - SMAK0 - Prof Claim SMAK0 Alaska
Hawaii Medicare - SMHI0 - Prof Claims SMHI0 Hawaii
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
Partners Behavioral Health Management - 52613 - Prof Claim 52613 States unavailable for Partners Behavioral Health Management - 52613 - Prof Claim
Delaware Medicaid - SKDE0 - Prof Claims SKDE0 Delaware
Security Health Plan - 39045 - Prof Claims 39045 States unavailable for Security Health Plan - 39045 - Prof Claims
Value Options/ MBHP (MA Behavioral Health Partnership) - 43307 - Prof Claims 43307 States unavailable for Value Options/ MBHP (MA Behavioral Health Partnership) - 43307 - Prof Claims
Highmark Senior Health - - 95462 - Prof Claim 95462 States unavailable for Highmark Senior Health - - 95462 - Prof Claim
Railroad Medicare - SRRGA - Prof Claims SRRGA ~All States
Tricare for Life - SX176 - Prof Claim SX176 States unavailable for Tricare for Life - SX176 - Prof Claim
Wisconsin Medicare - SMWI0 - Prof Claim SMWI0 Wisconsin
New Jersey BCBS - 22099 - Prof Claims 22099 New Jersey
California Medicaid - SKCA0 - Prof Claims SKCA0 California
Iowa Medicaid - SKIA0 - Prof Claim SKIA0 Iowa
Maine Medicare - SMME0 - Prof Claims SMME0 Maine
Maine Medicaid - SKME0 - Prof Claim SKME0 Maine
Utah Medicare - SMUT0 - Prof Claim SMUT0 Utah
Oregon Medicare - SMOR0 - Prof Claim SMOR0 Oregon
Minnesota Medicare - SMMN0 - Prof Claim SMMN0 Minnesota
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
Montana BCBS Medical - SB751 - Prof Claims SB751 Montana
New York Medicare GHI - SMNY2 - Prof Claim SMNY2 New York
Wyoming Medicare - SMWY0 - Prof Claim SMWY0 Wyoming
Rhode Island Medicare - SMRI0 - Prof Claims SMRI0 Rhode Island
Washington Medicaid - SKWA0 - Prof Claims SKWA0 Washington
South Carolina Medicaid - SKSC0 - Prof Claims SKSC0 South Carolina
Michigan Medicaid Medical - SKMI0 - Prof Claims SKMI0 Michigan
Hawaii Medicaid - SKHI0 - Prof Claims SKHI0 Hawaii
New York Medicare Empire - SMNY0 - Prof Claim SMNY0 New York
New Jersey Medicaid - SKNJ0 - Prof Claims SKNJ0 New Jersey
Wyoming Medicaid - SKWY0 - Prof Claims SKWY0 Wyoming
Idaho Medicare - SMID0 - Prof Claims SMID0 Idaho
Nevada Medicare - SMNV0 - Prof Claims SMNV0 Nevada