Emdeon Dental Payer List

220 Burnham Street ● South Windsor, CT 06074
Vox 888-255-7293 ● Fax 860-289-0055
HOW TO UN-ENROLL
DENTAL ELECTRONIC REMITTANCE ADVICE (ERA)
DISCONTINUING ERA
Discontinuing ERA is a 2 step process.
1. Deactivation
a. Providers receiving ERAs via their Practice
Management Software need to request
deactivation from their software Vendors. Please
call your PMS directly.
b. Providers receiving their ERAs via an Emdeon DPS
account need only ignore the ERA option when
logging into the DPS.
2. Payer Un-enrollment
a. Each payer has their own unique process to
discontinue ERAs and return to paper Remittance
Advice. Please identify which payers you wish to
un-enroll from and follow the instructions for unenrollment in the far right column next to each of
your payers.
CONTACT PHONE NUMBER
Emdeon Dental Provider Enrollment
888-255-7293
Page 1 of 1
11-15-13: dlv
Emdeon Dental Payer List
1/19/2015
Payer
AARP
ID
AARP1
ERA Un-Enrollment Process
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
Advantica Benefits
43168
Email request to [email protected]. Include provider name and Tax ID.
Aetna
60054
Provider would need to mark Cancel and complete section A of the Electronic Remittance
Advice & Electronic Fund Transfer Request Form and fax to 859-455-8650.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
AGC International Union of Operating Engineers Local 701
AK United Food and Commercial Workers (AK UFCW)
Alask Carpenters
Alaska Hotel Employees, Restaurant & Camp Employees (AK HERE)
1
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
Ameritas Life Insurance Corp.
47009
No un-enrollment is required by the payer. Paper EOPs can be obtained at
http://www.ameritas.com/index.htm
Ameritas Life insurance Corp. of New York
72630
No un-enrollment is required by the payer. Paper EOPs can be obtained at
http://www.ameritas.com/index.htm
Alaska Laborers Construction Industry Health & Security Trust
Alaska Machinists Health and Welfare Trust
Alaska Pipe Trades U A Local 375
Alaska Public Employees Association (APEA/JESS Health & WelfareTrust)
Allied Metal Crafts Security Plan Trust Fund
2
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Association Benefit Plan
25133
Email request to [email protected]. Include provider name and Tax ID.
Assurant Health (IM & GROUP FULLY - INSURED )
39065
If a provider wishes to discontinue receiving ERAs from Assurant Health / Time Insurance
Co. email request to [email protected] making sure to include his Tax ID, name
and mailing address.
Benefit Inc.
R7003
Benefit Systems & Services, Inc. (BSSI)
36342
Contact Delta Dental of Minnesota Professional Services department either via phone or
in writing stating your request.
Phone: 800-328-1188
Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Email request to [email protected]. Include provider name and Tax ID.
Please visit one of the below sites to request to discontinue ERA services.
Blue Care Family Plan
California State Government Programs
GWD01
CPPCA
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
CareFirst, Inc. Maryland BCBS
00580
3
Email request to [email protected]. Include provider name and Tax ID.
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
91136
Email request to [email protected]. Include provider name and Tax ID.
Central Reserve Life
34097
Email request to [email protected]. Include provider name and Tax ID.
CHAMPVA - HAC
84147
Email request to [email protected]. Include provider name and Tax ID.
CIGNA
62308
Email request to [email protected]. Include provider name and Tax ID.
Community Health Electronic Claims/CHEC/webTPA
75261
Email request to [email protected]. Include provider name and Tax ID.
Connecticut General (CIGNA)
62308
Email request to [email protected]. Include provider name and Tax ID.
Cooperative Benefit Administrators (CBA)
52132
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
Cement Masons and Plasterers Health & Welfare Trust
4
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
CoreSource Little Rock
75136
If a provider wishes to discontinue receiving ERAs from CoreSource Little Rock email the
request to [email protected]
CoreSource MD PA IL
35182
If a provider wishes to discontinue receiving ERAs from CoreSource MD PA IL email
request to [email protected]
CoreSource NC IN
35180
If a provider wishes to discontinue receiving ERAs from CoreSource NC IN email request
to [email protected]
Coventry Health Care
25133
Email request to [email protected]. Include provider name and Tax ID.
Coventry Health Care Carelink
25133
Email request to [email protected]. Include provider name and Tax ID.
Coventry Health Care Carelink Medicaid
25133
Email request to [email protected]. Include provider name and Tax ID.
Coventry Health Care National Network
25133
Email request to [email protected]. Include provider name and Tax ID.
5
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Coventry Missouri
25133
Email request to [email protected]. Include provider name and Tax ID.
CTI Administrators
42141
Email request to [email protected]. Include provider name and Tax ID.
Dart Management Corp.
06172
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Contact DeCare Networks Professional Services department either via phone or in writing
stating your request.
Phone: 800-658-4187
Fax: 800-658-4186
Mail: PO Box 1175, Minneapolis, MN 55440-1175
DeCare Dental Health Insurance
07035
Dental Benefit Providers
52133
Email request to [email protected]. Include provider name and Tax ID.
Dental Select
CX093
Email request to [email protected]. Include provider name and Tax ID.
Deseret Mutual Benefit Administrators
CX089
Contact DMBA EDI Enrollment via email to [email protected] or via phone at
800-777-3622.
6
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
EMI Health
CX079
If a provider wishes to discontinue receiving ERAs from EMI Health call 800-662-5851
and make his request.
Employers Mutual, Inc.
59297
Email request to [email protected]. Include provider name and Tax ID.
EQUICOR
62308
Email request to [email protected]. Include provider name and Tax ID.
ExclusiCare
71412
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
Fairbanks North Star Borough
Fairbanks North Star Borough School District Plan A (FNSBSD)
Fairbanks North Star Borough School District Plan B (FNSBSD)
7
Emdeon Dental Payer List
1/19/2015
Payer
First Reliance Standard Life Ins. Co. (NY Business)
ID
13317
Flex Compensation
R7004
Foreign Service Benefit Plan
25133
ERA Un-Enrollment Process
No un-enrollment is required by the payer. Paper EOPs can be obtained at
http://www.ameritas.com/index.htm
Contact Delta Dental of Minnesota Professional Services department either via phone or
in writing stating your request.
Phone: 800-328-1188
Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Email request to [email protected]. Include provider name and Tax ID.
Please visit one of the below sites to request to discontinue ERA services.
GIC Indemnity Plan
80314
Gilsbar, Inc.
07205
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Email request to [email protected]. Include provider name and Tax ID.
Please visit one of the below sites to request to discontinue ERA services.
Golden West Dental
Government Employees Hospital Association (GEHA)
GWD01
44054
8
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
If a provider wishes to discontinue receiving ERAs from GEHA email request to
[email protected].
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Great-West Healthcare
80705
Email request to [email protected]. Include provider name and Tax ID.
Group Benefit Administrators
72153
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Guardian Life Insurance Company of America
64246
Email request to [email protected]. Include provider name and Tax ID.
Hawaii - Mainland Administrators
86066
Email request to [email protected]. Include provider name and Tax ID.
Hawaii Medical Service Association (HMSA)
HMSA1
Email request to [email protected]. Include provider name and Tax ID.
Hawaii Western Management Association (HMAA/HWMG)
99208
Email request to [email protected]. Include provider name and Tax ID.
Health Choice Arizona
62179
Email request to [email protected]. Include provider name and Tax ID.
9
Emdeon Dental Payer List
1/19/2015
Payer
Healthgram, Inc.
ID
56144
ERA Un-Enrollment Process
Email request to [email protected]. Include provider name and Tax ID.
Providers based in MN who no longer wish to receive their HealthPartner ERAs from
Emdeon must enroll online at
https://www.healthpartners.com/providerregistration/entry.do to receive their
remittance advices online.
HealthPartners MN
CX009
Providers based outside MN who no longer wish to receive their HealthPartner ERAs from
Emdeon should email request to [email protected]. Include provider name
and Tax ID.
Healthplex, Inc.
11271
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
HealthSCOPE Benefits, Inc.(Formerly CNA Health Partners of Arkansas)
71063
Email request to [email protected]. Include provider name and Tax ID.
HealthSmart Benefit Solutions
37272
Email request to [email protected]. Include provider name and Tax ID.
HealthSmart Benefit Solutions
87815
If a provider wishes to discontinue receiving ERAs from Wells Fargo Third Party
Administrators email request to [email protected]
91136
Email request to [email protected]. Include provider name and Tax ID.
Hotel Employees Restaurant Employees Health Trust (HERE)
10
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Humana, Inc.
61101
• Email request to [email protected].
• Include provider name and Tax ID.
Insurance Program Managers Group (IPMG)
36342
Email request to [email protected]. Include provider name and Tax ID.
John Alden Life Insurance Co.
41099
If a provider wishes to discontinue receiving ERAs from John Alden Life Insurance Co.
email request to [email protected] making sure to include Tax ID, name and
mailing address.
Jopari Careworks
J1410
Log on to Jopari Portal at www.jopari.com using your unique User ID and Password to
access the ERA Enrollment menu. A menu will allow you to select 'Reason for
Submission' to enable you to discontinue ERAs and return to paper Remittance Advice.
91136
Email request to [email protected]. Include provider name and Tax ID.
Mail Handlers Benefit Plan
25133
Email request to [email protected]. Include provider name and Tax ID.
Mayo Clinic Health Solutions
41154
Provider must call MMSI Customer Service at 800-533-1564 and make a request.
Locals 302 & 612 of the Internation Union of Operating Engineers
11
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
MBS
56205
Email request to [email protected]. Include provider name and Tax ID.
MED3000 CMS Early Steps
EM350
Email request to [email protected]. Include provider name and Tax ID.
Med3000 CMS Title 19 Reform
EM843
Email request to [email protected]. Include provider name and Tax ID.
Med3000 CMS Title 21
EM205
Email request to [email protected]. Include provider name and Tax ID.
MED3000 Pedicare Title 21
EM522
Email request to [email protected]. Include provider name and Tax ID.
MedCost Benefit Services
56205
Email request to [email protected]. Include provider name and Tax ID.
MEDICA of Minnesota
CX026
12
Contact Delta Dental of Minnesota Professional Services department either via phone or
in writing stating your request.
Phone: 800-328-1188
Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Medical Benefits Mutual Administrators (MedBen)
74323
Email request to [email protected]. Include provider name and Tax ID.
Medical Mutual of Ohio
29076
If a provider wishes to discontinue receiving ERAs from Medical Mutual of Ohio call
Provider Contracts at 800-625-2583.
Medical Mutual of Ohio
CB833
If a provider wishes to discontinue receiving ERAs from Medical Mutual of Ohio call
Provider Contracts at 800-625-2583.
Medico Insurance Company
23160
Email request to [email protected]. Include provider name and Tax ID.
Mercy Care Plan
86052
If a provider wishes to discontinue receiving ERAs from Mercy Care Plan call 602-2633000 or 800-624-3879 Express Service Code 631.
Mercy Maricopa Integrated Care
33628
Please contact Mercy Maricopa Integrated Care for assistance. 602-586-1880 or 866602-1979
MetLife
65978
Please visit https://www.metdental.com/prov/execute/home for
instructions.
13
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Municipal Health Benefit Fund
81883
Email request to [email protected]. Include provider name and Tax ID.
Mutual of Omaha Commercial
CX087
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Mutual of Omaha Insurance Company
71412
Email request to [email protected]. Include provider name and Tax ID.
Mutually Preferred
71412
Email request to [email protected]. Include provider name and Tax ID.
National Rural Letter Carrier Association
71412
Email request to [email protected]. Include provider name and Tax ID.
New England Dental Administrators
43351
Email request to [email protected]. Include provider name and Tax ID.
Nippon Life Insurance Company of America
81264
Email request to [email protected]. Include provider name and Tax ID.
14
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
J1410
No un-enrollment is available. Jopari CareWorks requires claims submitted EDI (837D)
to have remits delivered EDI (835).
Northwest Ironworkers Health & Security Fund
Northwest Roofers & Employers Health & Security Trust Fund
Northwest Textile Processors and Service Trades
NW International Association of Machinists (NW IAM)
NW Plumbers & Pipefitters Health & Welfare Trust
Ohio Dept of Corrections (Careworks)
OK State Employees & Educators (EDS)
22521
15
Providers should submit a new agreement with the Reason for Submission denoted as
Cancel Enrollment to the below.
In Network providers fax to 405-717-8977
Non Network providers email to [email protected].
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
PacificSource Health Plans
93029
Providers who wish to discontinue receiving ERAs need to call PacificSource Health Plans
and make the request. 800-624-6052
PEHP (Public Employees Health Program)
CX080
Please call or email the PEHP helpdesk at 801-366-7544, 800-753-7818 or
[email protected] to request discontinuance of ERAs.
Physicians Mutual
CX068
No un-enrollment is required by the payer. Paper EOPs can be obtained at
http://www.ameritas.com/index.htm
Pittman & Associates
37224
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
POMCO
16111
If a provider wishes to discontinue receiving ERAs from POMCO call 315-432-9171 ext.
4255.
Preferred Care Partners
65088
Email request to [email protected]. Include provider name and Tax ID.
Preferred One
41147
Email request to [email protected]. Include provider name and Tax ID.
16
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
PrimeWest Health
LX049
Paper remits are not available effective 1-1-13. Providers can access the Prime West
Health Portal to obtain explanation of payment (EOP). Please contact the Call Center for
assistance at 866-431-0802.
Principal Financial Group
61271
Email request to [email protected]. Include provider name and Tax ID.
Priority Health
38217
Email request to [email protected]. Include provider name and Tax ID.
91136
Email request to [email protected]. Include provider name and Tax ID.
36088
No un-enrollment is required by the payer. Paper EOPs can be obtained at
http://www.ameritas.com/index.htm
Puget Sound Electrical Workers Healthcare Trust (PSEW)
Reliance Standard Life
Please visit one of the below sites to request to discontinue ERA services.
Reliastar
80314
Renaissance Life and Health
RLHA1
17
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Emdeon Dental Payer List
1/19/2015
Payer
Reserve National Insurance Company
ID
73066
ERA Un-Enrollment Process
Email request to [email protected]. Include provider name and Tax ID.
Please visit one of the below sites to request to discontinue ERA services.
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Rocky Mountain Life Dental
84102
Rural Carrier Benefit Plan
25133
Email request to [email protected]. Include provider name and Tax ID.
SafeGuard PPO
CX030
Please visit https://www.metdental.com/prov/execute/home for
instructions.
Contact DeCare Networks Professional Services department either via phone or in writing
stating your request.
Phone: 800-658-4187
Fax: 800-658-4186
Mail: PO Box 1175, Minneapolis, MN 55440-1175
Securian
93742
Select Health
CX107
Please call 801-442-5442 and request to be returned to paper remits.
Sheffield, Olson and McQueen
41143
Provider would need to mark Cancel and complete section A of the Electronic Remittance
Advice & Electronic fund Transfer Request Form and fax to 651-389-9152.
18
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Standard Ins. Co. (OR Business)
93024
No un-enrollment is required by the payer. Paper EOPs can be obtained at
http://www.ameritas.com/index.htm
Standard Insurance Company (NY)
13411
No un-enrollment is required by the payer. Paper EOPs can be obtained at
http://www.ameritas.com/index.htm
Sun Life and Health Insurance Company
67814
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
Surency Life and Health
CX088
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
Time Insurance Company
39065
If a provider wishes to discontinue receiving ERAs from Assurant Health / Time Insurance
Co. email request to [email protected] making sure to include his Tax ID, name
and mailing address.
Total Broker Benefits
36342
Email request to [email protected]. Include provider name and Tax ID.
Total Dental Administrators
CX112
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
19
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
TransChoice - Key Benefit Administrators
37284
Email request to [email protected]. Include provider name and Tax ID.
UMR - Wausau/UHIS
39026
Email request to [email protected]. Include provider name and Tax ID.
Please visit one of the below sites to request to discontinue ERA services.
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
UNICARE
80314
United Concordia - Dental Plus
CX013
Email request to [email protected]. Include provider name and Tax ID.
United Concordia - Fee for Service
CX007
Email request to [email protected]. Include provider name and Tax ID.
United Concordia - Tricare Dental Plan
CX002
Email request to [email protected]. Include provider name and Tax ID.
United of Omaha
71412
Email request to [email protected]. Include provider name and Tax ID.
20
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
University of Missouri
25133
Email request to [email protected]. Include provider name and Tax ID.
UPMC Health Plan
23281
Email request to [email protected]. Include provider name and Tax ID.
VA Fee Basis Programs
12116
If a provider wishes to discontinue receiving ERAs from Val Fee Basis Programs fax a
letter of request to Emdeon at 860-289-0055.
91136
Email request to [email protected]. Include provider name and Tax ID.
Web TPA, Inc of TX
59332
If a provider wishes to discontinue receiving ERAs from Wells Fargo Third Party
Administrators email request to [email protected]
Wells Fargo TPA, Inc (Charleston, WV)
87815
If a provider wishes to discontinue receiving ERAs from Wells Fargo Third Party
Administrators email request to [email protected]
Wells Fargo TPA, Inc. (Newnan, GA and Fayetteville, NC)
37272
Email request to [email protected]. Include provider name and Tax ID.
Washington State Council of County & City Employees (WSCCCE)
21
Emdeon Dental Payer List
1/19/2015
Payer
WilsonMcShane
ID
R7002
ERA Un-Enrollment Process
Contact Delta Dental of Minnesota Professional Services department either via phone or
in writing stating your request.
Phone: 800-328-1188
Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
36123
Email request to [email protected]. Include provider name and Tax ID.
Horizon Healthcare Dental Services
22099
If a provider wishes to discontinue receiving ERAs from Horizon Healthcare Dental
Services fax a letter of request to the payer at 973-274-4154 attention Shirley Antoine.
The letter must be typed on office letterhead and contain Tax ID and Provider name.
NorthStar Administrators
47570
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
Premera Blue Cross
47570
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
Blue Cross of Alaska and Washington
47570
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
Blue Cross of Alabama
CBAL1
If a provider wishes to discontinue receiving ERAs from Blue Cross of Alabama fax
request to 205-220-9266 on office letterhead.
Dearborn National
22
Emdeon Dental Payer List
1/19/2015
Payer
Blue Cross of Arkansas
ID
CBAR1
ERA Un-Enrollment Process
Email request to [email protected]. Include provider name and Tax ID.
Please visit one of the below sites to request to discontinue ERA services.
Anthem Blue Cross CA
47198
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Please visit one of the below sites to request to discontinue ERA services.
Blue Cross of Colorado
84099
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Please visit one of the below sites to request to discontinue ERA services.
Trigon Blue Cross Blue Shield - Colorado Dental Office
84103
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Please visit one of the below sites to request to discontinue ERA services.
Anthem Blue Cross Blue Shield Connecticut
84105
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Please visit one of the below sites to request to discontinue ERA services.
Blue Care Family Plan (BCBS of CT)
00700
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Please visit one of the below sites to request to discontinue ERA services.
Blue Cross of Georgia
CBGA1
23
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Blue Cross of Iowa
CBIA2
If a provider wishes to discontinue receiving ERAs from Blue Cross of Iowa complete the
Electronic Transaction Registration Form leaving the 835 box blank. The form is
available at http://wellmark.com/e_business/provider/forms/frmsprovider.htm.
Blue Shield of Idaho
CBID2
No un-enrollment is necessary at Providers will continue to be able to see their remits in
the Regence Provider Center websites.
Blue Cross of Illinois
CB621
Email request to [email protected]. Include provider name and Tax ID.
Blue Cross of Kansas
CBKS1
If a provider wishes to discontinue receiving ERAs from Blue Cross of Kansas fax the
request to 785-290-0720. Provider letterhead is preferred but not mandated.
Please visit one of the below sites to request to discontinue ERA services.
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Blue Cross of Kentucky Anthem
84105
Blue Cross Blue Shield of Louisiana
23739
Submit a new Electronic Remittance Advice (ERA) Enrollment Form directly to LA BCBS
denoting the Reason for Submission as Cancel Enrollment.
Blue Cross of Massachusetts
CBMA1
Send request to [email protected]. Include the provider's name, Tax ID
and NPI.
24
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Blue Cross Blue Shield of Michigan
CBMI1
Email request to [email protected]. Include provider name and Tax ID.
Also, if you enrolled for Medicare Advantage and FEP for BCBS Michigan you will need to
contact them directly to discontinue ERA. 800-542-0945 or [email protected].
Blue Cross Blue Shield of Kansas City MO
47171
If a provider wishes to discontinue receiving ERAs from Blue Cross Blue Shield of Kansas
City MO fax the request to 785-290-0720. Provider letterhead is preferred but not
mandated. Also an email must be sent to [email protected] requesting ERAs
be discontinued.
Blue Cross of Mississippi
CBMS1
If a provider wishes to discontinue receiving ERAs from BCBS of Mississippi call 800-8264068.
Blue Cross Blue Shield of Montana
CBMT1
Contact your Montana BCBS representative.
Blue Cross of North Dakota (ND Dental Services)
CX004
If a provider wishes to stop receiving ERAs, a Termination Form is required to be
submitted to ND BCBS. Please call EDI Support Services for the form and instructions.
Blue Cross of Nebraska
CBNE1
If a provider wishes to discontinue receiving ERAs from BC of Nebraska call Sean Blair at
402-392-4205.
Blue Cross of New Mexico
SB790
Email request to [email protected]. Include provider name and Tax ID.
25
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Please visit one of the below sites to request to discontinue ERA services.
Blue Cross of Nevada
Empire Blue Cross Blue Shield
84101
CBNY1
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Contact DeCare Networks Professional Services department either via phone or in writing
stating your request.
Phone: 800-658-4187
Fax: 800-658-4186
Mail: PO Box 1175, Minneapolis, MN 55440-1175
Please visit one of the below sites to request to discontinue ERA services.
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Blue Cross of Ohio Anthem
84105
Blue Cross blue Shield of Oklahoma
SB840
Email request to [email protected]. Include provider name and Tax ID.
Blue Cross blue Shield of Oregon
CB850
No un-enrollment is necessary at Providers will continue to be able to see their remits in
the Regence Provider Center websites.
Pennsylvania Blue Shield
CB865
Email request to [email protected]. Include provider name and Tax ID.
CBPA2
Email request to [email protected]. Include provider name and Tax ID.
Pennsylvania Blue Shield Dental Plus
26
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
CB870
If a provider wishes to discontinue receiving ERAs from BC of Rhode Island mail a letter
of request on letterhead which contains the provider's full name, Tax ID and/or Provider
ID, Submitter ID and reason for discontinuance to: Attn: Contracting Department Blue
Cross of Rhode Island, 15 LaSalle Square, Providence, RI 02903.
South Carolina BCBS
38520
Effective 1-1-10: Paper RAs are no longer available from South Carolina BCBS. Should a
provider wish to discontinue receiving ERAs from Emdeon the provider needs to re-enroll
for ERA retrieval through SC BCBS or re-enroll electing another entity to retrieve their
ERAs from SC BCBS. Provider may contact BlueCross Provider Education at 803-2644730 for additional information.
Blue Cross of Texas
CB900
Email request to [email protected]. Include provider name and Tax ID.
Regence UT BCBS
CBUT1
No un-enrollment is necessary at Providers will continue to be able to see their remits in
the Regence Provider Center websites.
Regence UT BCBS FEP
CBUTF
No un-enrollment is necessary at Providers will continue to be able to see their remits in
the Regence Provider Center websites.
Blue Cross of Rhode Island
Please visit one of the below sites to request to discontinue ERA services.
Trigon Blue Cross of Virginia (Anthem BCBS-VA/ BCBS Anthem-VA formerly Trigon)
CB923
Blue Cross of Alaska and Washington
47570
27
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
Emdeon Dental Payer List
1/19/2015
Payer
Regence Blue Shield
ID
93200
ERA Un-Enrollment Process
No un-enrollment is necessary at Providers will continue to be able to see their remits in
the Regence Provider Center websites
Please visit one of the below sites to request to discontinue ERA services.
Blue Cross of Wisconsin
Delta Dental Insurance Co. (DDIC) - All Payers
CB950
94276
All states - https://www.anthem.com/dentalproviders/
GA - http://www.bcbsga.com/home-providers.html
NY - http://www.empireblue.com/home-providers.html
CA - https://www.anthem.com/dentalproviders/
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
Northeast Delta Dental (ME, NH, VT)
02027
Email request to [email protected]. Include provider name and Tax ID.
Delta Dental of Arizona
86027
If a provider wishes to discontinue receiving ERAs from Delta Dental of Arizona send a
written request to the below address. Please include the provider’s name, Tax ID, and
statement of request. Delta Dental of Arizona PO Box 43000 Phoenix, AZ 85080-3000
Delta Dental of California - CA00 Claims Office
77777
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
Delta Dental of Washington DC
52147
28
Email request to [email protected]. Include provider name and Tax ID.
Emdeon Dental Payer List
1/19/2015
Payer
Delta Dental of Delaware
ID
51022
ERA Un-Enrollment Process
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
Delta Dental of Iowa
CDIA1
If a provider wishes to discontinue receiving ERAs from Delta Dental Iowa a new
enrollment form with the reason for submission denoted as Cancel needs to be submitted
to Delta Dental of Iowa.
Fax 515-261-5608
or
Email [email protected]
Delta Dental of Idaho
82029
Any provider with questions about enrollment in the ERA program should just call
our customer service department at: 208-489-3580 or 800-356-7586 or email to
[email protected].
Delta Dental of Illinois Group Plans
05030
Providers are required to give Delta Dental of Illinois written notification. Mail
notifications to: Professional Relations Department Delta Dental of Illinois 801 Ogden
Avenue Lisle, IL 60532
Delta Dental of Indiana
CDIN1
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Delta Dental of Kansas
CDKS1
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
Delta Dental of Kentucky
CDKY1
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
29
Emdeon Dental Payer List
1/19/2015
Payer
Delta Dental of Maryland and Pennsylvania
ID
23166
ERA Un-Enrollment Process
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
Delta Dental of Michigan
Blue Cross and Blue Shield of Minnesota
CDMI0
CDMN1
Delta Dental of Minnesota
CDMN1
Delta Dental of North Carolina
56101
Delta Dental of North Dakota
Delta Dental of Nebraska
CDND1
CDNE1
30
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Contact Delta Dental of Minnesota Professional Services department either via phone or
in writing stating your request.
Phone: 800-328-1188
Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Contact Delta Dental of Minnesota Professional Services department either via phone or
in writing stating your request.
Phone: 800-328-1188
Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Contact Delta Dental of Minnesota Professional Services department either via phone or
in writing stating your request.
Phone: 800-328-1188
Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Contact Delta Dental of Minnesota Professional Services department either via phone or
in writing stating your request.
Phone: 800-328-1188
Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Delta Dental of New Jersey
22189
Please contact DDNJ at 800-452-9310 and request to return to paper remits.
Delta Dental of New Mexico
85022
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Delta Dental of New York
11198
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
Delta Dental of Ohio
CDOH1
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Delta Dental of Oklahoma
CDOK1
None required as provider will continue to receiver paper remits.
Delta Dental of Maryland and Pennsylvania
Delta Dental Puerto Rico
23166
66043
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
31
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Delta Dental of Tennessee
CDTN1
If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta
Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life
& Health email request to [email protected]
Delta Dental of Virginia
CDVA1
Complete a new form following the directions for cancellation. Submit the form to:
Delta Dental of Virginia 4818 Starkey Road, Roanoke, VA 24018
Delta Dental of Washington
91062
Email request to [email protected]. Include provider name and Tax ID.
Delta Dental of Wisconsin
39069
If a provider wishes to discontinue receiving ERAs from Delta Dental Wisconsin email
request to [email protected] or call Provider Relations at 800-836-0490.
Delta Dental of West Virginia
31096
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written
notification to Delta’s Dental Network Administration and Contracting department. Allow
ninety (90) days for business data validation, setup, testing and production
implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request
to:
Delta Dental of California Dentist Network Administration and Contracting (DNAC)
P.O. Box 537010
Sacramento, CA 95853-7010
Or
fax to: (916) 852-8995
Medicaid of Alaska
CKAK1
A faxed letter of request must be sent on letterhead to 907-644-8126 to request
disenrollment. Please note the letter needs to be signed by the contact person listed in
Alaska Medicaid’s system.
Medicaid of Alabama
CKAL1
If a provider wishes to discontinue receiving ERAs from Alabama Medicaid contact
Provider Enrollment at 800-456-1242 or 334-215-0111.
32
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Medicaid of Arkansas
CKAR1
If a provider wishes to discontinue receiving ERAs from Arkansas Medicaid call 800-4574454 or 501-376-221.
Denti-Cal / Medicaid of California
94146
If a provider wishes to discontinue receiving ERAs from Denti-Cal / Medicaid of California
call 916-853-7373 and make the request.
Medicaid of Connecticut
CKCT1
If a provider wishes to discontinue receiving ERAs from Medicaid of Connecticut he needs
to fax a letter of request to 860-269-2027. The letter must include the statement, “I no
longer want to receive 835s”, the provider’s name, Tax ID and address.
District of Columbia Medicaid
CKDC1
If a provider wishes to discontinue receiving ERAs from Washington, D.C. Medicaid mail a
letter of request on letterhead which contains the provider's full name, Tax ID and
Provider ID with the reason for discontinuance to: ACS Provider Enrollment Unit, PO Box
4761, Washington, DC 20043-4761.
Delaware Medicaid
CKDE1
If a provider wishes to discontinue ERAs with Delaware Medicaid a written letter of
request must be completed on the office’s letterhead with an authorized signature and
mailed to: Delaware Medicaid, Provider Relations, PO Box 909, Manor Branch, New
Castle, DE 19720
Medicaid of Florida
CKFL1
If a provider wishes to discontinue receiving ERAs from Florida Medicaid mail a letter or
request on letterhead with provider signature to: ACS State Healthcare - Provider
Enrollment, 2308 Killearn Ctr. Blvd., Ste. 100, Tallahassee, FL 32309.
Medicaid of Georgia
CKGA1
If a provider wishes to discontinue receiving ERAs from Georgia Medicaid mail a Remit
Option Form to ACS, PO Box 4000, McRae, GA 31055. The form can be found at
www.ghp.georgia.gov.
33
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Medicaid of Iowa
CKIA1
Effective 3-1-10, un-enrollment will no longer be allowed as paper remits will cease.
Providers may only change where they retrieve ERAs from.
Aetna Better Health of Illinois
26337
Contact Aetna Better Health of Illinois
Indiana Childrens Special Healthcare
CX070
If a provider wishes to discontinue receiving ERAs from Emdeon the provider needs to reenroll for ERA retrieval through the Indiana Medicaid web portal selecting another entity
to retrieve their ERAs from Indiana Medicaid.
Medicaid of Indiana
CKIN1
If a provider wishes to discontinue receiving ERAs from Emdeon the provider needs to reenroll for ERA retrieval through the Indiana Medicaid web portal selecting another entity
to retrieve their ERAs from Indiana Medicaid.
Medicaid of Kansas
CKKS1
If a provider wishes to discontinue receiving ERAs from Emdeon login to the KMAP
account and remove WEBMDDENTAL as the receiver of 835s. 835s will than begin being
delivered to the provider’s KMAP account. Should a provider wish to return to paper RAs
call the KMAP Customer Service line at 800-933-6593 option 1, option 3#.
Medicaid of Kentucky
CKKY1
If a provider wishes to discontinue receiving ERAs from Kentucky Medicaid call 800-2054696.
Medicaid of Maine
CKME1
Providers must log into their Maine MIHMS account and remove Emdeon as the receiver
of their 835 transactions
34
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Medicaid of Michigan
CKMI1
Providers deciding to no longer have their ERAs delivered to Emdeon need to go into the
CHAMPS system and place an end date for Emdeon as the receiver.
Medicaid of Minnesota
CKMN1
Not allowed per Minnesota Statutes 62J.536 which requires electronic only RAs by
12/15/09. Providers may however opt to remove Emdeon as their ERA clearinghouse by
completing another Electronic Remittance Advice (RA) Request Form designating another
receiver.
Providers based in MN who no longer wish to receive their HealthPartner ERAs from
Emdeon must enroll online at
https://www.healthpartners.com/providerregistration/entry.do to receive their
remittance advices online.
HealthPartners MN
CX010
Providers based outside MN who no longer wish to receive their HealthPartner ERAs from
Emdeon should email request to [email protected]. Include provider name
and Tax ID.
Medicaid of Missouri
CKMO1
If a provider wishes to discontinue receiving ERAs from Missouri Medicaid call the
Infocrossing Healthcare Services Help Desk at 573-635-3559.
Medicaid of Mississippi
CKMS1
Paper RAs are no longer available from Mississippi Medicaid. Should a provider wish to
discontinue receiving ERAs from Emdeon the provider needs to re-enroll for ERA retrieval
through the Mississippi Medicaid web portal or re-enroll electing another entity to retrieve
their ERAs from Mississippi Medicaid.
Medicaid of Montana
CKMT1
If a provider wishes to discontinue receiving ERAs from Montana Medicaid mail request
to: DPHHS, PO Box 202951, Helena, MT 59620-2951
Medicaid of North Carolina
CKNC1
Effective July 1, 2013 all Provider Enrollment Applications and updates must be
completed through the NCTracks system.
35
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Aetna Better Health of Nebraska
42130
Contact Aetna Better Health of Nebraska
Medicaid of Nebraska
CKNE1
If a provider wishes to discontinue receiving ERAs from Nebraska Medicaid submit a
Nebraska Medicaid Trading Partner Authorization form listing an end date.
Medicaid of New Hampshire
CKNH1
If a provider wishes to discontinue receiving ERAs from New Hampshire Medicaid send a
letter of request to: EDS, PO Box 2040, Concord, NH 03302-2040.
Aetna Better Health Plan of New Jersey
46320
Contact Aetna Better Health of New Jersey
Medicaid of New Jersey
CKNJ1
If a provider wishes to discontinue receiving ERAs from New Jersey Medicaid send a
letter of request on letterhead with an authorized signature to: NJ Medicaid, PO Box
4804, Trenton, NJ 08650.
New Mexico Medicaid
CKNM1
Email request to [email protected]
Medicaid of Nevada
CKNV1
If a provider wishes to discontinue ERAs with Nevada Medicaid complete a new FH-37
form completing the terminate a transaction section. Forms are available at:
https://nevada.fhsc.com/Downloads/provider/FH37_service_center_authorization_form.pdf
36
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Medicaid of New York
CKNY1
If a provider wishes to discontinue receiving ERAs from NY Medicaid complete the
Electronic Remittance 835/820 Request form denoting paper as method of remittance
retrieval. The form should than be faxed to 518-257-4632.
Medicaid of New York (Dental Clinics Only)
CKNY2
If a provider wishes to discontinue receiving ERAs from NY Medicaid complete the
Electronic Remittance 835/820 Request form denoting paper as method of remittance
retrieval. The form should than be faxed to 518-257-4632.
NYS DOH UCP
14142
Email request to [email protected]. Include provider name and Tax ID.
Aetna Better Health of Ohio
50023
Contact Aetna Better Health of Ohio
Medicaid of Ohio
CKOH1
Submit a new enrollment form directly to Ohio Medicaid with section VI denoted as
Cancel Enrollment.
Medicaid of Oklahoma
CKOK1
If a provider wishes to discontinue receiving ERAs from Oklahoma Medicaid submit a new
EDI 835 application marking the box titled, Disable the 835 and resume paper RA
effective immediately.
Medicaid of Oregon
CKOR1
If a provider wishes to discontinue receiving ERAs from Oregon Medicaid submit a
change form (Exhibit C). Providers should call 503-947-5347 for instructions and a copy
of the form.
37
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Medicaid of Pennsylvania
CKPA1
If a provider wishes to discontinue ERAs send request to the EDI Department, 225
Grandview Avenue, Mail Stop B100, Camp Hill, PA 17011 or [email protected]. The
request must include the provider name, Tax ID, Promise number, Group Promise
number, contact person, phone number and date they wish to stop receiving ERAs and
return to paper.
Medicaid of Rhode Island
CKRI1
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
Medicaid of Texas
CKTX1
If a provider wishes to discontinue receiving ERAs from Texas Medicaid call the EDI
Helpdesk at 888-863-3638 option 3.
Medicaid of Utah
CKUT1
If a provider wishes to discontinue receiving ERAs from Utah Medicaid visit the online
enrollment tool for Utah Medicaid and remove Emdeon's Trading Partner number from
the line titled 835 Remittance Advice. The web address for the tool is
http://hcf.health.utah.gov/hcfenroll/index.jsp
Medicaid of Vermont
CKVT1
If a provider wishes to discontinue receiving ERAs from Vermont Medicaid call 802-8794450 or email [email protected]
Medicaid of Washington
CKWA1
Providers who wish to discontinue receiving ERAs need to call Washington DHS at 800562-3022 and make the request.
Medicaid of Wisconsin
CKWI1
No un-enrollment is necessary as the provider will always continue to receive paper
remittance advice statements.
38
Emdeon Dental Payer List
1/19/2015
Payer
ID
ERA Un-Enrollment Process
Medicaid of West Virginia
CKWV1
Please log into your WV Medicaid provider portal account and remove
CPSI EDI dba Emdeon Dental as the receiver of your ERAs.
Medicaid of Wyoming
CKWY1
If a provider wishes to discontinue receiving ERAs from Wyoming Medicaid mail request
to: Attn: EDI Enrollment Unit, PO Box 667, Cheyenne, WY 82003 or fax to 307-7728405. The request should be on office letterhead and include Tax ID, NPI, name and
mailing address.
39