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Payor Enrollment Forms

The payors listed below require enrollment before claims can be processed electronically through DentalXChange. Prior to submitting any claims to these payors, please download the appropriate form(s) from the list below and follow the instructions to enroll. These forms will be available to download until all eClaims are fully functional.

Payor NamePayor IdEnrollment Form
BCBS of TennesseeCBTN1Download Enrollment Application
Blue Cross Blue Shield of MississippiCBMS1Download Enrollment Application
DC Medicaid77033Download Enrollment Application
Deseret Mutual Benefit Administrators (DMBA)DX214Download Enrollment Application
HealthPartners of Minnesota94267Download Enrollment Application
Medicaid of AlaskaCKAK1Download Enrollment Application
Medicaid of FloridaCKFL1Download Enrollment Application
Medicaid of IowaCKIA1Download Enrollment Application
Medicaid of KentuckyCKKY1Download Enrollment Application
Medicaid of Louisiana EPSDTCKLA1Download Enrollment Application
Medicaid of Maine (MaineCare)CKME1Download Enrollment Application
Medicaid of MichiganCKMI1Download Enrollment Application
Medicaid of MinnesotaCKMN1Download Enrollment Application
Medicaid of Minnesota (Administered by HealthPartners of Minnesota)94267Download Enrollment Application
Medicaid of MississippiCKMS1Download Enrollment Application
Medicaid of NevadaCKNV1Download Enrollment Application
Medicaid of New JerseyCKNJ1Download Enrollment Application
Medicaid of New YorkCKNY1Download Enrollment Application
Medicaid of North CarolinaCKNC1Download Enrollment Application
Medicaid of TexasCKTX1Download Enrollment Application
Medicaid of UtahCKUT1Download Enrollment Application
Medicaid of VermontCKVT1Download Enrollment Application
Medicaid of WyomingCKWY1Download Enrollment Application
Medi-Cal94146Download Enrollment Application
Public Employee Health Program (PEHP)CX080Download Enrollment Application