Payor Enrollment Forms
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 |
|
|
Blue Cross Blue Shield of Mississippi |
CBMS1 |
Blue_Cross_Blue_Shield_of_Mississippi_-_Claims_Enrollment_Application |
|
DC Medicaid |
77033 |
|
|
Deseret Mutual Benefit Administrators (DMBA) |
DX214 |
Deseret_Mutual_Benefit_Administrators_DMBA_-_Claims_Enrollment_Application |
|
HealthPartners of Minnesota |
94267 |
|
|
Medicaid of Alaska |
CKAK1 |
|
|
Medicaid of Florida |
CKFL1 |
|
|
Medicaid of Iowa |
CKIA1 |
|
|
Medicaid of Kentucky |
CKKY1 |
|
|
Medicaid of Louisiana EPSDT |
CKLA1 |
|
|
Medicaid of Maine (MaineCare) |
CKME1 |
|
|
Medicaid of Michigan |
CKMI1 |
|
|
Medicaid of Minnesota |
CKMN1 |
|
|
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 Nevada |
CKNV1 |
|
|
Medicaid of New Jersey |
CKNJ1 |
|
|
Medicaid of New York |
CKNY1 |
|
|
Medicaid of North Carolina |
CKNC1 |
|
|
Medicaid of Texas |
CKTX1 |
|
|
Medicaid of Utah |
CKUT1 |
|
|
Medicaid of Vermont |
CKVT1 |
|
|
Medicaid of Wyoming |
CKWY1 |
|
|
Medi-Cal |
94146 |
|
|
Public Employee Health Program (PEHP) |
CX080 |
Public_Employee_Health_Program_PEHP_-_Claims_Enrollment_Application |