Payor Enrollment Forms

how to enroll

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 Name

Payor Id

Enrollment Form

BCBS of Tennessee

CBTN1

BCBS_of_Tennessee_-_Claim_Enrollment_Application

Blue Cross Blue Shield of Mississippi

CBMS1

Blue_Cross_Blue_Shield_of_Mississippi_-_Claims_Enrollment_Application

DC Medicaid

77033

DC_Medicaid_-_Claims_Enrollment_Application

Deseret Mutual Benefit Administrators (DMBA)

DX214

Deseret_Mutual_Benefit_Administrators_DMBA_-_Claims_Enrollment_Application

HealthPartners of Minnesota

94267

HealthPartners_of_Minnesota_-_Claims_Enrollment_Application

Medicaid of Alaska

CKAK1

Medicaid_of_Alaska_-_Claims_Enrollment_Application

Medicaid of Florida

CKFL1

Medicaid_of_Florida_-_Claims_Enrollment_Application

Medicaid of Iowa

CKIA1

Medicaid_of_Iowa_-_Claims_Enrollment_Application

Medicaid of Kentucky

CKKY1

Medicaid_of_Kentucky_-_Claims_Enrollment_Application

Medicaid of Louisiana EPSDT

CKLA1

Medicaid_of_Louisiana_EPSDT_-_Claims_Enrollment_Application

Medicaid of Maine (MaineCare)

CKME1

Medicaid_of_Maine_MaineCare_-_Claims_Enrollment_Application

Medicaid of Michigan

CKMI1

Medicaid_of_Michigan_-_Claims_Enrollment_Application

Medicaid of Minnesota

CKMN1

Medicaid_of_Minnesota_-_Claims_Enrollment_Application

Medicaid of Minnesota (Administered by HealthPartners of Minnesota)

94267

Medicaid_of_Minnesota_Administered_by_HealthPartners_of_Minnesota_-_Claims_Enrollment_Application

Medicaid of Mississippi

CKMS1

Medicaid_of_Mississippi_-_Claims_Enrollment_Application

Medicaid of Nevada

CKNV1

Medicaid_of_Nevada_-_Claims_Enrollment_Application

Medicaid of New Jersey

CKNJ1

Medicaid_of_New_Jersey_-_Claims_Enrollment_Application

Medicaid of New York

CKNY1

Medicaid_of_New_York_-_Claims_Enrollment_Application

Medicaid of North Carolina

CKNC1

Medicaid_of_North_Carolina_-_Claims_Enrollment_Application

Medicaid of Texas

CKTX1

Medicaid_of_Texas_-_Claims_Enrollment_Application

Medicaid of Utah

CKUT1

Medicaid_of_Utah_-_Claims_Enrollment_Application

Medicaid of Vermont

CKVT1

Medicaid_of_Vermont_-_Claims_Enrollment_Application

Medicaid of Wyoming

CKWY1

Medicaid_of_Wyoming_-_Claims_Enrollment_Application

Medi-Cal

94146

Medi-Cal_Claims_Enrollment_Application

Public Employee Health Program (PEHP)

CX080

Public_Employee_Health_Program_PEHP_-_Claims_Enrollment_Application