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Dental Enrollment Forms (Payor I.D.)

• Alabama Blue Cross Blue Shield (CBAL1)

  - Tax I.D. change form
• Alabama Medicaid (CKAL1)
  

  - Tax I.D. change form
• Alaska Medicaid (CKAK1)
• Arkansas Blue Cross Blue Shield (CBAR1) - Call UCCI @ 800-633-5430 for registration info.
• California Medicaid - Please call us or request via email (info@lindtech.com) to have the forms sent to you.
• CHIPS: Childrens low cost Texas health plan administered by UCCI - Call UCCI @ 800-633-5430 for Provider I.D. #.
• Colorado Medicaid (CKCO1)
  - EDI Update
• Connecticut Medicaid (22235) - Enrollment no longer required.
• Doral Dental or DMERC (CX014) - Additional enrollment no longer required. Call Doral Dental to obtain a provider I.D.
• Florida Medicaid (55555)
• Georgia Blue Cross Blue Shield (H0143) - Enrollment no longer required.
• Georgia Medicaid (E0920)
• Idaho Blue Cross (CBID1)
• Idaho Blue Shield (CBID2)
• Idaho Medicaid (E0900)
• Illinois Blue Cross Blue Shield (BS018) - Additional enrollment no longer required.
• Indiana Medicaid (MDIN1) - Enrollment no longer required.
• Iowa Blue Cross Blue Shield (Iowa Blue Dental - Wellmark)(CBIA1, CBIA2)
• Iowa Medicaid (CKIA1)
• John Deere (95378) - call LTC
• Kansas Blue Cross Blue Shield (CBKS1)
• Kansas Medicaid (CKKS1) - Enrollment no longer required.
• Kentucky Medicaid (CKKY1)

  - Kentucky Medicaid (Individual to Group Practice Change Only)
• Louisiana Blue Cross - Call BC of Louisiana @ 225-297-2758 for Provider I.D.#.
• Louisiana Medicaid (CKLA1, CKLA2)
  
• Maine Medicaid (CKME1)
• Massachusetts Blue Cross Blue Shield (CBMA1, PPO:CBMA2)
• Medical Mutual of Ohio - Call MMO @ 850-625-2583 for Provider I.D.#
• Michigan Medicaid - Please call us or request via email (info@lindtech.com) to have the forms sent to you.
• Minnesota Medicaid (Minnesota Medical Assistance) (MNMA1)
• Mississippi Blue Cross Blue Shield (BBMS1)
• Mississippi Medicaid (E3240)
• Missouri Medicaid (CKMO1) - Enrollment no longer required.
• Montana Medicaid (CKMT1, MTMDC) - enrollment no longer required.
• Nevada Medicaid (CKNV1)
• New Hampshire Medicaid (E3360)
• New Jersey Blue Cross Blue Shield (Horizon Healthcare) (22099)
• New Jersey Medicaid (66665)
• New Mexico Medicaid (CKNM1)
• New York Medicaid (CKNY1, CKNY2)
• North Carolina Medicaid - (CKNC1) - Enrollment no longer required.
• North Dakota Dental Services (ND Blue Cross Blue Shield) (CX004)
• Ohio Medicaid Caresource - Call Caresource @ 937-224-8313 for Provider I.D. #.
• Oklahoma Medicaid (E0880) - enrollment no longer required.
• Oregon Blue Cross Blue Shield (66668)
• Oregon Medicaid (CKOR1)
• Pennsylvania Blue Shield - Call UCCI @ 800-633-5430 for registration info.
• Pennsylvania Medicaid (CKPA1)
• Rhode Island Blue Cross Blue Shield (53473)
• Rhode Island Medicaid (22100)
• South Carolina Medicaid (CKSC1)
• Tennessee Blue Cross Blue Shield (CBTN1)
• Texas Blue Cross Blue Shield (84980) - Call TX BCBS for provider I.D.
• Texas CHIP (Children's Health Insurance Program) Dental Services (CPPTX) - If instruction is required for completing the form, call the Texas CHIP Provider Call Center at 866-561-5891.
• Texas Medicaid - Call Medicaid of Texas @ 800-925-9126 for enrollment info.
• Tricare Family Members Dental Plan - Call UCCI @ 800-633-5430 for registration info.
• Trigon Blue Cross of Virginia - Call Trigon for Provider I.D. #.
• United Concordia (UCCI1, UCCIP. 30000) - fill out form and submit electronically (auto-sends via email)
• Vermont Medicaid (CKVT1)
• Virginia Medicaid (CKVA1) - Additional enrollment no longer required. Call VA Medicaid for provider I.D.
• Washington Medicaid (MDWA1) - includes ProviderOne enrollment update instructions.
• West Virginia Medicaid (CKWV1)
• Wisconsin Blue Cross Blue Shield (22226) - Additional enrollment no longer required.
• Wisconsin Blue Cross Blue Shield W-9 Form - Additional enrollment no longer required.
• Wisconsin Medicaid (MDWI1) - Additional enrollment no longer required.
• Wyoming Medicaid (CKWY1)

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Medical Enrollment Forms

• Alabama Blue Cross Blue Shield (BBAL1) - download form via ENS.
• Alabama Medicaid (MDAL1) - download form via ENS.
• Alabama Medicare(MRAL1) - download form via ENS.
• Alaska Blue Cross Blue Shield (Premera) (BBWAP)
• Alaska Medicaid(MDAK1) - download form via ENS.
• Alaska Medicare (MRAK1)
• AmeriHealth -(Administrators, Delaware, New Jersey) - HMO and non-HMO - Enrollment Online
• Arizona Blue Cross Blue Shield (BBAZ1) - download form via ENS.
• Arizona Medicaid (MDAZ1) - download form via ENS.
• Arizona Medicare (MRAZ1)
• Arkansas Blue Cross Blue Shield (BBAR1)
• Arkansas Medicaid (MDAR1) - download form via ENS.
• Arkansas Medicare (MRAR1)
• AultCare - Ohio (AULTC) - download form via ENS.
• Behavioral Healthcare Providers (BHP01)
• California Medicaid (MDCA1) - download form via ENS.
• California Medicare (Northern) (MRCAN)
• California Medicare (Southern) (MRCAS)
  • California Medicare (Southern) Change Request Form (MRCAS
• Care Choices HMO
• CareSource - Ohio (31114) - enrollment no longer required.
• Colorado Blue Cross Blue Shield (BBCO1)
• Colorado Medicaid (MDCO1) - download form via ENS.
• Colorado Medicare (MRCO1)
• Connecticut Blue Cross Blue Shield (BBCTE) - download form via ENS.
• Connecticut Medicaid (MDCT1) - download form via ENS.
• Connecticut Medicare (MRCT1)
• DC / NCA Blue Cross Blue Shield (CareFirst) (BBDCC) - download form via ENS.
• DC Medicaid (MDDC1) - download form via ENS.
• DC Medicare (MRDC1)
• Delaware Blue Cross Blue Shield (BBDE1)
• Delaware Medicaid (MDDE1) - download form via ENS.
• Delaware Medicare (MRDE1)
• DMERC - all regions (DMRCA, DMRCB, DMRCC, DMRCD) - Use the following info:
  
  Submitter Status -- Please Select -- New Submitter Existing Submitter

  *
  Submitter ID

  *
  Submitter Name

  *
  Submitter Type -- Please Select -- Clearinghouse Billing Service Third Party Biller Self Biller
• EBMS (Employee Benefit Management Services, Inc.) (81039)
• Florida Blue Cross Blue Shield (BBFL1)
• Florida Medicaid (MDFLE) - download form via ENS.
• Florida Medicare (MRFL1)
• Freedom Blue (Highmark) (71768) - Enrollment Online
• Geisinger Health Plan (30594) - Call for enrollment (888-281-5338 option 3)
• Georgia Blue Cross Blue Shield (BBGA1)
• Georgia Medicaid (MDGA1) - download form via ENS.
• Georgia Medicaid - Peach State Behavioral (MDGA2) - download form via ENS.
• Georgia Medicaid - Peach State Health Plan (MDGA3) - download form via ENS.
• Georgia Medicaid - Wellcare (MDGA4) - download form via ENS.
• Georgia Medicare (MRGA1)
• Hawaii Blue Cross Blue Shield (BBHIE) - download form via ENS.
• Hawaii Medicaid (MDHIE) - download form via ENS.
• Hawaii Medicare (MRHIE) - download form via ENS.
• Health Partners (HLTHC) - Email LTC (info@lindtech.com) with with the following information:
  • Provider practice name and group NPI (if they have one)
  • Individual provider names and NPI's.
  • LTC will notify you when enrollment is complete.
• Hill Physicians Medical Group - call HPMG (800-445-5747) to obtain a Provider I.D.
• Idaho Blue Cross Blue Shield (BBID1) - download form via ENS.
• Idaho Medicaid (MDID1)
• Idaho Medicare (MRID1)
• Illinois Blue Cross Blue Shield (BBIL1)
• Illinois Medicaid - IDPA (MDILE)
• Illinois Medicare (ILMR1)
• Indiana Blue Cross Blue Shield (BBIN1) - download form via ENS.
• Indiana Medicaid (MDIN1) - download form via ENS.
• Indiana Medicare (MRIN1)
• Iowa Blue Cross Blue Shield (Wellmark) (BBIAW)
• Iowa Medicaid (MDIA1) - Enrollment Online - if asked for a clearinghouse to be used, enter "EClaims".
• Iowa Medicare (MRIA1)
• Kansas Blue Cross Blue Shield (BBKS1)
• Kansas City Blue Cross Blue Shield (BBKC1)
• Kansas City Medicare (MRKC1)
• Kansas Medicaid (MKS1) - download form via ENS.
• Kansas Medicare (MRKS1)
• Kentucky Medicaid (MDKY1) - download form via ENS.
• Kentucky Medicare (MRKY1)
• Keystone Health Plan (Central, East) - Enrollment Online
• Louisiana Blue Cross Blue Shield (BBLAE) - download form via ENS.
• Louisiana Medicaid (MDLA1) - download form via ENS.
• Louisiana Medicare (MRLA1)
• Maine Blue Cross Blue Shield (BBME1)
• Maine Medicaid (MDME1) *Be sure to read the instruction .pdf included with the enrollment form link. - download form via ENS.
• Maine Medicare (MRME1)
• Maryland Blue Cross Blue Shield (BBMD1)
• Maryland Medicaid (MDMD1) - download form via ENS.
• Maryland Medicare (MRMD1)
• Massachusetts Blue Cross Blue Shield (BBMAE) - download form via ENS.
• Massachusetts Medcaid (MDMA1) - download form via ENS.
• Massachusetts Medicare (MRMA1)
• Michigan Blue Cross Blue Shield or Blue Care (including FEP) - (BBMIF) - Enrollment Online
  One form per provider number, whether for a group or individual number.
  Note: Unique receiver I.D. and submitter I.D. is C0HDA (second digit is a zero).
• Michigan Medicaid (MDMI1) - download form via ENS.
• Michigan Medicare (MIMR1)
• Minnesota Blue Cross Blue Shield (BBMN1, BPMN1, BPMNS) - Enrollment Online - Email LTC (info@lindtech.com) with with the following information:

  • Provider practice name and group NPI (if they have one)
  • Individual provider names and NPI's.
  • LTC will notify you when enrollment is complete.
• Minnesota Medicaid (MNMD1)
• Minnesota Medicare - MMA (MRMN1)
• Mississippi Blue Cross Blue Shield (BBMS1)
• Mississippi Medcaid (MDMS1) - download form via ENS.
• Mississippi Medcare (MAMS1) - Call LTC.
• Missouri - Kansas City (NW Missouri) Medicare (MRKC1)
• Missouri - Kansas City Blue Cross Blue Shield (BBKC1)
• Missouri Blue Cross Blue Shield (BBMO1) - download form via ENS.
• Missouri Medcaid (MDMO1) - download form via ENS.
• Missouri Medicare (MRMO1)
• Montana Blue Cross Blue Shield (BBMT1)
• Montana Medcaid (MTMD1) - download form via ENS.
• Montana Medicare (MRMT1)
• Nebraska Blue Cross Blue Shield (BBNE1)
• Nebraska Medicaid (MDNEE) - download form via ENS.
• Nebraska Medicare (MRNE1)
• Nevada Blue Cross Blue Shield (BBNV1)
• Nevada Medicaid (MDNV1) - download form via ENS.
• Nevada Medicare (MRNVN)
• New Hampshire Blue Cross Blue Shield (BBNHE) - download form via ENS.
• New Hampshire Medicaid (MDNH1) - download form via ENS.
• New Hampshire Medicare (MRNH1)
• New Jersey Blue Cross Blue Shield (Horizon) (BBNJ1)
• New Jersey Medicaid (MDNJ1) - download form via ENS.
• New Jersey Medicare (MRNJ1)
• New Mexico Medicare (MRNM1)
• New York Blue Cross Blue Shield (Empire) (BBNYE)
• New York Blue Cross Blue Shield - Central New York (BBNYC) - download form via ENS.
• New York Blue Cross Blue Shield - Rochester (BBNYR) - download form via ENS.
• New York Blue Cross Blue Shield - Western New York (BBNYW) - download form via ENS.
• New York Medicaid (MDNY1) - download form via ENS.
• New York Medicare (Empire) (MRNYE)
• New York Medicare - GHI (MRNYG) - download form via ENS.
• New York Medicare - Upstate (MRNYU) - download form via ENS.
• North Carolina Blue Cross Blue Shield (BBNC1)
• North Carolina Medicaid (MDNC1) - enrollment no longer required.
• North Carolina Medicare (MRNC1)
• North Dakota Blue Cross Blue Shield (BBND1)
• North Dakota Medicaid (MDND1) - download form via ENS.
• North Dakota Medicare (MRND1)
• Ohio BWC (Multiple Payors) DO NOT FAX TO THE NUMBER ON THE FORM. Fax to 719-785-5290 - download form via ENS.
• Ohio Medicaid (OHMD1) - No enrollment required. Call LTC with your Provider I.D. number.
• Ohio Medicare (Part B) (OHMR1)
  • Ohio Medicare (Part B) Termination/Change Request Form (OHMR1)
• Oklahoma Blue Cross Blue Shield (BBOK1) - download form via ENS.
• Oklahoma Medicaid (MDOK1) - download form via ENS.
• Oklahoma Medicare (MROK1)
• Oregon Blue Cross Blue Shield (BBOR1) - download form via ENS.
• Oregon Medicaid (MDOR1)
• Oregon Medicare (MROR1)
• Pennsylvania Blue Shield (Highmark, Independence) - Enrollment Online
• Pennsylvania Medicaid (MDPA1) - download form via ENS.
• Pennsylvania Medicare (MRPA1)
• Preferred Care (PCARE)
• Providence Health Plans (PHP01)
• Railroad Medicare (Palmetto Government Benefit Administrators) (MRRR2)
  • Railroad Medicare EDI Provider (Clearinghouse) Change Form
• Rhode Island Blue Cross Blue Shield (BBRI1) - download form via ENS.
• Rhode Island Medicaid (MDRI1) - download form via ENS.
• Rhode Island Medicare (MRRI1)
• South Carolina Blue Cross Blue Shield (BBSCE) - download form via ENS.
• South Carolina Medicaid (MDSC1) - download form via ENS.
• South Carolina Medicare (MRSC1)
• South Dakota Blue Cross Blue Shield (Wellmark) (BBSDW)
• South Dakota Medicaid (MDSD1) - download form via ENS.
• South Dakota Medicare (MRSDN)
• Tennessee Blue Cross Blue Shield (BBTN1)
• Tennessee Medicaid (MDTN1) - download form via ENS.
• Tennessee Medicare (MRTN1)
• Texas Blue Cross Blue Shield (BBTX1) - enrollment no longer required.
• Texas Medicaid (MDTXE) - download form via ENS.
• Texas Medicare (MRTX1) - call LTC for info.
• Tricare - North and South (TRICN) - download form via ENS.
• Tricare - West (TRICW)
• Utah Blue Cross Blue Shield (BBUTE) - download form via ENS.
• Utah Medicaid (MDUT1) - download form via ENS.
• Utah Medicare (MRUTN)
• Vermont Blue Cross Blue Shield (BBVT1)
• Vermont Medicaid (MDVT1)
• Vermont Medicare (MRVT1)
• Virginia Blue Cross Blue Shield (BBVAE) - Enrollment no longer required.
• Virginia Medicaid (MDVA1) - download form via ENS.
• Virginia Medicare (MRVA1)
• Washington Blue Cross (Premera) (BBWAP)
• Washington Blue Cross Blue Shield (Regence) (BBWAR) - Enrollment no longer required. Call WA BCBS Regence for provider I.D.
• Washington Medicaid (MDWA1) - download form via ENS.
• Washington Medicare (MRWAN)
• Washington State L & I (Labor & Industry) (SX063)
• West Virginia Blue Cross Blue Shield (BBWV1) - download form via ENS.
• West Virginia Medicaid (MDWV1) - download form via ENS.
• West Virginia Medicare (WVMR1)
• Wisconsin Blue Cross Blue Shield (BBWI1)
• Wisconsin Medicaid (MDWI1) - download form via ENS.
• Wisconsin Medicare (WIMR1)
• WPS Commercial (WPSC1)
• Wyoming Blue Cross Blue Shield (BBWY1) - download form via ENS.
• Wyoming Medicaid (MDWY1) - download form via ENS.
• Wyoming Medicare (MRWY1) - download form via ENS.

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For all other Payor/Carrier additional enrollment forms not listed, please use the ENS enrollment procedure listed below.

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Enrollment Forms: via ENS

Please note: Do not download or click on any other carrier form other than the one you are seeking.

• Click here for carrier enrollment forms from ENS - Once the page loads, select the state for your carrier from the drop down list box and then click on the emc agreement .pdf form for the carrier you wish to enroll with.

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Electronic Remittance Advice(ERA) Authorization Forms and Instructions

Dental

• Ohio Medicaid (E0340)

Medical

• Aetna (60054) - Use this fax number instead of what is listed in the form: 719-785-5290
• Cigna (62308) - Use this fax number instead of what is listed in the form: 719-785-5290
• DMERC- all regions (DMRCA, DMRCB, DMRCC, DMRCD) - Use submitter ID: B08002584
• Florida Medicare (MRFL11)
• HealthPartners (HLTHC) - email LTC to set it up.
• Humana (61101) - instructions for online enrollment.
• Indiana Medicare (MRIN1) - For "Submitter ID" use: Z8FR
• Landmark Healthcare (LNDMK)
• Medica (MEDIC) - Use this fax number instead of what is listed in the form: 719-785-5290
• MHP(10850) - Contact MHP Provider Services at 877-620-9090. Arrange to get the ERA through "Emdeon". Notify us (LTC) once you have completed this.
• Minnesota Blue Cross Blue Shield (BBMN1, BPMN1, BPMNS) - Call or email LTC to set up your provider.
• Minnesota Medicaid (MNMA1) - Providers will be able to download either the 835 or an EOB as Adobe PDF from the MN Medicaid web site. LTC, Inc. can also arrange to send these along with standard LTC reports to the provider. Begin with completion of this application.
• MMSI (41154) - email LTC to set it up.
• Ohio Blue Cross Blue Shield (BBOH1)
• Ohio Medicaid (OHMD1)
• Railroad Medicare (MRRR2)
• Tricare North (TRICN)
• Tricare West (TRICW)
• UCare (19991)
• United Healthcare (87726) - Use this fax number instead of what is listed in the form: 719-785-5290
• WPS Commercial (WPSC1)
• WPS Medicare (including Illinois, Iowa, Kansas, Kansas City, Michigan, Minnesota, Missouri, Nebraska and Wisconsin Medicare)

Download Software for Printing Medical 835 ER

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New Client Enrollment Forms for Providers and/or Billing Centers new to LTC

• New Client Enrollment Forms required by LTC, Inc.
  

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