eClaims Dental Payer List Information

eClaims Dental Payer List Information

Payer IDs are required to send your claims electronically. When you add a new insurance company in your system,

please use this payer list to find the Insurance Company’s Payer ID.

• Payer IDs can be entered by going to List|Insurance Companies|Edit the Insurance Company and enter the payer

ID number in the ‘Claim Payer Id field’

• If you are working with Blue Cross/Blue Shield or Medicaid you will also need to update the payment source

accordingly

Payer List Includes: Commercial Payers – Pages 1-15

Blue Cross Blue Shield Payers – Pages 15-17

Delta Dental Payers – Page 17-18

Medicaid Payers – Pages 18-19

Payer ID 06126: Use this eClaims payer id for those insurance companies that are not listed on

this eClaims Payer List

Group Number Column: Yes = the payer requires the group number

No = the group number is optional

Enroll Column: This column indicates whether or not the payer requires enrollment prior to

accepting your claims electronically

Yes = Payer requires enrollment please do the following for these payers:

1. Within EagleSoft go to Online|FAQ

2. Under the Search by Keyword field type 4400

3. Click on the eClaims Additional Enrollment Paperwork

No = No paperwork is required

Real Time Claims: Y = Payer participates in Real Time Claims

Know what insurance companies will pay on the rendered services within

seconds and know the patient portion while the patient is still at the office.

Real Time Pre Estimates: Y = Payer participates in Real Time Pre Estimates

Additional Information Column: This column includes important information specific to the insurance

companies.

Obtaining Current Payer List: Recommended every 2-3 months

1. Go to Online|FAQ or pattfaq.com

2. Under the Search by Keyword field type 2453

3. Click on eClaims Payer List and Payer List Changes

For additional questions, please contact the eServices Support Team by using Live Chat, Help|Live Help,

or calling 800-475-5036.

eClaims Dental Payer List

April 2020

State Payer ID Group # EnrollReal Time Claims

*

Real Time Pre

Estimates* Additional Info

A & I Benefit Plan Administrators 93044 Yes No

A.D.N. Administrators, Inc. CXADN Yes No

AARP AARP1 Yes NoAARP Claims with a mailing address of PO Box

2059, Mechanicsburg, PA

Acceptius (Benefit Management Inc of

MO (BMI)43178 Yes No

Access Dental CX097 Yes No via Performance Health Technology

Acclaims 64071 Yes No

ACS Benefit Services Inc. 72468 Yes No f.k.a. ACS Consulting Services, Inc.

Activa Benefit Services, LLC/Dental 38255 Yes No (Formerly Amway Corporation/Dental)

Administrative Services, Inc. 59141 Yes No

Administrative Services Only, Inc. CX076 Yes No

Additional enrollment is not required by the payer,

however, providers wishing to submit Claims

electronically must be credentialed with the payer.

Please ensure you have successfully process one

paper Claims with the payer prior to submitting

your first electronic Claims.

Advantage by Superior CPPSA Yes Yes

Effective only for Dates of Service prior to 2-01-

13. Call DentaQuest at 800-896-2374 and MCNA

Dental at 855-776-6262 for Dates of Service 2-1-

13 and greater.

Advantage Dental Plan, Inc. 93524 No No

Advantek Benefit Administrators 83077 Yes No

Advantica Benefits 43168 Yes No Y Y

Aetna 60054 Yes No

Aetna Affordable Health Choices (SM) -

SRC57604 Yes No

Aetna Medicare EPO/PPO Dental 18014 Yes No

Affordable Benefits Admin. 95426 Yes No

AFLAC GA - GRP 58066 Yes NoGroup Plan coverage please refer to your ID card

for group coverage/number verification.

AFLAC NY 52080 Yes No

This plan also shares the same mailing address

as payer ID 58066 and the only difference

between the plans is that the insured ID for the

NY based plan begins with "PN" as "PNxxxxxx"

(followed by 6+ digits)

AFLAC NY - GRP 52080 Yes NoGroup Plan Coverage please refer to your ID card

for group coverage/number verification.

AGC International Union of Operating

Engineers Local 70191136 Yes No

Please enter group # F07 when submitting claims.

A Welfare and Pension Administration Services

payer

AK United Food and Commercial

Workers (AK UFCW)91136 Yes No



payer

Alask Carpenters 91136 Yes No



payer

Alaska Electrical Health & Welfare

Fund92600 Yes No

Alaska Hotel Employees, Restaurant &

Camp Employees (AK HERE)91136 Yes No



payer

Alaska Laborers Construction Industry

Health & Security Trust91136 Yes No



payer

Alaska Machinists Health and Welfare

Trust91136 Yes No



payer

Alaska Pipe Trades U A Local 375 91136 Yes No



payer

Alaska Public Employees Association

(APEA/JESS Health & WelfareTrust)91136 Yes No



payer

For an updated payer list please visit our website www.eaglesoft.net

Page 1


April 2020


*

Real Time Pre


Alexian Brothers Community Services

of TN44423 Yes No

AllCare CCO Dental CXALC Yes No via Performance Health Technology

Allegeant 52193 Yes No f.k.a. LBA Health Plans

Allegiance Benefit Plan 81040 Yes No

Alliant Services 70106 Yes NoClaims mailing address of PO Box 12009,

Cheshire, CT

Allied Benefit Systems 37308 Yes No

Allied Metal Crafts Security Plan Trust

Fund91136 Yes No



payer

Allina Health Plan 54398 No

AlwaysCare Benefit STR01 No

Amalgamated Life - PA Alicare 13343 Yes No

Ameraplan 38219 Yes No

Ameriben Solutions 75137 Yes No

American Administrators dba Select

Benefit Administrators (West Des

Moines, IA)

42137 Yes No

Please check the Insured ID card to verify the

Payer ID before submitting claims. If you have

questions, please contact Provider Relations at

800-456-4584.

American Benefit Corporation CX084 Yes No

Only limited plans may be sent electronically.

Group name is required with one of the following

plan names: Sheet Metal, Berekely, Boone,

Carpenter, Cabell, Clarksbur, Doodridge,

Hancock, Harrison, Marion, Monongalia, Mingo,

Mineral, Morgan, Nicholas, Putnam, Taylor, Tyler,

Wetzel.

American Medical Security CX001 Yes No A United Healthcare Payer

American Postal Workers Union Health

Plan44444 Yes No

Americas TPA 41178 Yes No

Amerihealth Administrators 54763 Yes No

Ameritas Life Insurance Corp. 47009 Yes No

Ameritas Life insurance Corp. of New

York72630 Yes No

Amway Corporation 38255 Yes No (Formerly Amway Corporation/Dental)

Anchor Benefit 53085 Yes No

Antares Management Solutions 34192 No No

Apostrophe, Inc. 81312 Yes No

ARC Administrators CXARC Yes No

Argus Dental Plans, Inc. ARGUS Yes No

Arkansas Superior Direct 61184 Yes No

ASR Corporation 38265 Yes No

Association Benefit Plan 25133 Yes No

Formerly payer ID 62413. Now part of Coventry

Consolidate payer ID. Including Combined

Government Health Plan & Contract Health

Insurance Plan.

Assurant Employee Benefits 70408 Yes No PO Box 2877, Clinton, IA 52733

Assurant, Inc, 70408 Yes No PO Box 2877, Clinton, IA 52733

Asuris 93221 Yes No

Atlantic Dental Inc. (ADI) - Commercial CX085 Yes No

Automated Benefit Services 38259 Yes No

Automated Group Administration, Inc.

(AGA)37280 Yes No

Avesis 86098 Yes No

Banner Health Systems SX145 Yes No

Banner Plan Administration 77078 Yes No

BARINet CB369 Yes No

BCI Administrators, Inc. 49153 Yes No

Beam BEAM1 Yes No

Beam CXBMD Yes No

Beam Dental CXBMD Yes No

Beam Ins Admin BEAM1 Yes No

Beam Ins Admin CXBMD Yes No

Beam Ins. BEAM1 Yes No

Beam Ins. CXBMD Yes No

Beam Insurance BEAM1 Yes No

Beam Insurance CXBMD Yes No

Beam Insurance Ad BEAM1 Yes No


Page 2


April 2020


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Beam Insurance Ad CXBMD Yes No

Beam Insurance Admin BEAM1 Yes No

Beam Insurance Admin CXBMD Yes No

Beam Insurance Administrator BEAM1 Yes No

Beam Insurance Administrator CXBMD Yes No

BEAM Insurance administrators BEAM1 Yes No

Beam Insurance Administrators BEAM1 Yes No

Bell Atlantic 68241 Yes No

BeneCare Dental Plans 23210 Yes No

Benefit Administrative Systems 36149 Yes No

Benefit Coordinators Corporation

(Pittsburgh, PA)25145 Yes No

Payer ID valid only for Claims with a submission

address of 111 Ryan Court, Suite 300, Pittsburgh,

PA 15205.

Benefit Inc. R7003 No No

Benefit Management Group NV 36459 Yes No

Benefit Management Services of MS 37212 Yes No

Benefit Management Services, Inc. 56139 Yes No

Benefit Management, Inc. of KS 48611 Yes No

Benefit Plan Administrators Co. (Eau

Claire, WI)39081 Yes No

Payer ID valid for Benefit Plan Administrators

(Eau Claire, WI submission address only) and

Custom Benefit Administrators

BIA CXBMD Yes No

BIA / Beam CXBMD Yes No

Blue BeneFit Administrators of MA 03036 Yes No a.k.a. CBA Blue

Blue Care Family Plan GWD01 No No Administered by Golden West (Well point)

Boilermakers National Health & Welfare

Fund36609 Yes No

Boon Administrative Services, Inc. BOONG Yes No

BridgeSpan Health (Regence Group) BRIDG Yes No

Brokers National CX032 Yes No

Broward Health 37314 Yes No

Butler Benefits 42150 Yes No

C. L. Frates CX075 Yes No

California State Government Programs CPPCA Yes No

Cannon Cochran Management

Services, Inc. Metairie, LA71057 Yes No

Payer ID for claims with a mailing address of PO

Box 6794, Metairie, LA 70009

Capitol Dental CX095 Yes No via Performance Health Technology

CareFirst, Inc. Maryland BCBS 00580 Yes No

Careington Benefit Solutions 60601 Yes No

CareOregon 93975 Yes No

Caresource GA GACS1 Yes No

Caresource IN INCS1 Yes No

Caresource KY KYCS1 Yes No

Caresource WV WVCS1 Yes No

Carolina Summit Healthcare 56195 Yes No

Carpenters Health and Welfare Fund of

PhiladelphiaCX101 Yes No

Cascade Health Alliance, Inc. CHA01 Yes No

Caterpillar Inc. 37060 Yes No A United Healthcare Payer

CBA Blue 03036 Yes No f.k.a. Comprehensive Benefits Administrators, Inc.

CCEA Teachers Health Trust 88019 Yes No

CDO Technologies 83028 Yes No

CDS Group Health 88022 Yes No

Cement Masons and Plasterers Health

& Welfare Trust91136 Yes No



payer

Central Reserve Life 34097 Yes NoOnly Non Medicare Supplement and Dental lines

of business administered under this payer ID.

Central States Health and Welfare

Fund36215 Yes No

Central Susquehanna Healthcare

Providers (CSHP)55731 Yes No An Innovative Healthware Services Payer.


Page 3


April 2020


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Real Time Pre


CHAMPVA - HAC 84147 Yes No

CHAMPVA - HAC is not associated with and does

not process Claims for TRICARE (formerly

CHAMPUS)

Chesterfield Resources, Inc.

(Uniontown, OH)34154 Yes No a.k.a. Salvation Army

Chewsi First Circle Solution / DD RI RICHW Yes nO Y Y

Choice Plus (TRW) 68241 Yes No

Christian Brothers Services 38308 Yes No

CIGNA 62308 Yes No

Citizens Security Life CX071 Yes No

Civil Service Employees Association

(CSEA)CX054 Yes No

Provider ID number required. Max of 50 procedure

lines per Claims. ID number must be 5 characters

in length, numbers 6 in length & ending with a '1'

are accepted when '1' is removed. Numbers with

leading zeros will have leading zeros omitted. ID

numbers cannot contain an "-".

ClaimsBridge HPN 11752 Yes No

Community Health Alliance of TN 27905 Yes No

Community Health Electronic

Claims/CHEC/webTPA75261 Yes No

Companion Life / KHP 37322 Yes No

CompBenefits CX021 Yes No

Comprehensive Healthcare options CHCP1 No

CompuSys / Erisa Group, Inc. 74234 No

Comsumers Choice Health Plan - State

of SC45321 Yes No

Connecticut Carpenters Health Fund 37307 Yes No

Connecticut General (CIGNA) 62308 Yes No

Consolidated Group Dental 61305 Yes No

Continental Benefits 35245 Yes No

Core Management Resources Group 58231 Yes No

Core V 60601 Yes No

CoreSource AZ MN 41045 Yes No

Only for Claims where the "submit Claims to

address" on the medical ID card is a CoreSource

address in the states of Arizona or Minnesota. For

assistance call 800-698-0106.

CoreSource Detroit 38225 Yes No

CoreSource KC 48117 Yes No f.k.a. FMH Benefit Services, Inc.

CoreSource Little Rock 75136 Yes No

CoreSource MD PA IL 35182 Yes No



address in the states of Maryland, Pennsylvania

or Illinois. For assistance call 800-689-0106.

CoreSource NC IN 35180 Yes No



address in the states of North Carolina or Indiana.

For assistance call 800-689-0106.

CoreSource OH 35183 Yes No

CoreStar 41045 Yes No





Covenant Administrators, Inc. (Atlanta,

GA)58102 Yes No f.k.a. Benesys, Inc.

Coventry Dental CX049 Yes No

Coventry Health Care 25133 Yes No West Virginia Only

Coventry Health Care Carelink 25133 Yes No West Virginia Only

Coventry Health Care Carelink

Medicaid25133 Yes No West Virginia Only

Coventry Health Care National Network 25133 Yes NoFormerly payer ID 87043. Now part of Coventry

Consolidated payer ID.

Coventry Health Care of Georgia 25148 Yes No


Page 4


April 2020


*

Real Time Pre


Coventry Missouri 25133 Yes NoFormerly payer ID 87043. Now part of Coventry


CoventryCares 86098 Yes NoKentucky Medicaid CoventryCares administered

by Avesis

Creative Plan Administrators 37320 No No

Crescent Dental - Meritain Health CX074 Yes No

Crescent Health Solution 56213 Yes No

CTI Administrators 42141 Yes No

CustomCare 68241 Yes No

Cypress Ancillary Benefits TLZ04 Yes No

Dart Management Corp. 06172 Yes No

DeCare Dental Health Insurance 07035 Yes No

Denex Dental CX049 Yes No

Dental Care Plus CX035 Yes No

Dental Health Services of America CX094 Yes No

Dental Network of MD CX034 Yes No

Dental Professionals of Wisconsin 39148 Yes No

f.k.a. Southeast Dental Associates. Effective 7-1-

14 payer name must be listed as DPOW-CCHP

OR DPOW-ANTHEM OR DPOW-ICA

Dental Select CX093 Yes No

Dentist Direct UTUDD No

Dentaquest Commercial Plans (Group

and Individual)04356 No No

Dentegra 88888 No

Deseret Mutual Benefit Administrators CX089 Yes Yes

DH Evans CX065 Yes No An Innovative Healthware Services Payer.

Diversified Administration Corporation CX040 Yes No

Downstream Casino 19191 Yes No

DQ/Emblem (Emblem Health Medicaid) EMBDQ No No

Dunn & Associates Benefits

Administrators, Inc.35186 Yes No

EBC, Inc. 37257 No No

Payer Id valid only for Claims with a billing

submission address of Employee Benefit

Consultants, located in Broadview Hts, OH,

Appleton, WI, Albuquerque, NM, Findlay, OH,

Louisville, KY and Milwaukee, WI

EBMC CX025 Yes No

EBMS (Employee Benefit Management

Services, Inc.)81039 Yes No

EBS - RMSCO EBSRM Yes No

EBS Benefit Solutions CX043 No No

EHI 73288 Yes No

Emblem Health (GHI - New York Group

Health Inc.)13551 Yes No

EMI Health CX079 Yes No

f.k.a. Educators Mutual Insurance Association.

Prior to accepting claims electronically EMIA

requires the provider to call 801-262-7476 or 800-

662-5850. Providers should advise EMIA that

they will be submitting their claims through

Change Healthcare Business Services, Inc. UHIN

submitter ID HT000214-001.

EMPHESYS 73288 Yes No

Employee Benefit Concepts

(Farmington Hills, MI)38241 Yes No

Employee Benefit Consultants 37257 No No

Payer Id valid only for Claims with a billing

submission address of Employee Benefit

Consultants, located in Broadview Hts, OH,

Appleton, WI, Albuquerque, NM, Findlay, OH,

Louisville, KY and Milwaukee, WI

Employee Benefit Management Corp

(EBMC)CX025 Yes No

Employee Benefits Plan Administration,

Inc. (E.B.P.A.)03036 Yes No a.k.a. CBA Blue

Employee Benefits Systems of IA 42149 Yes No

Employee Plans, LLC 35112 Yes No


Page 5


April 2020


*

Real Time Pre


Employer Plan Services, Inc. CX031 Yes No

Employers Direct Health 75232 Yes No

Employers Health 73288 Yes No

Employers Health Insurance 73288 Yes No

Employers Mutual, Inc. 59297 Yes No

Encara WDENC Yes No

Envolve Health 46278 Yes No f.k.a. Dental Health & Wellness

EPSI Dental II CX037 Yes No f.k.a. Capital Dental

EQUICOR 62308 Yes No

ES Beveridge and Associates 34108 Yes No An Innovative Healthware Services Payer.

E-V Benefits Management, Inc

(Columbus, OH)34159 Yes No

Everence 35605 Yes No

Evergreen Health Co-Op 93240 No

ExclusiCare 71412 Yes No

Fairbanks North Star Borough 91136 Yes No



payer

Fairbanks North Star Borough School

District Plan A (FNSBSD)91136 Yes No



payer

Fairbanks North Star Borough School

District Plan B (FNSBSD)91136 Yes No



payer

Fidelio Dental Insurance Company FDIC1 Yes No

fidelity / Key Select 37321 Yes No

First Continental Life & Accident

InsuranceCX090 Yes No

First Dental Health / BIA CXBMD Yes No

First Dental Health of CA CX086 Yes No

First Reliance Standard Life Ins. Co.

(NY Business)13317 Yes No

FL MCO PHC/PHP 95411 Yes No

Flex Compensation R7004 Yes No

FlexCare 68241 Yes No

Florida Combined Life CBFLU No

Florida Power & Light 68241 Yes No

Foreign Service Benefit Plan 25133 Yes No


Consolidated payer ID. Including AFSPA Staff

Plan.

Formula Card Dental LX050 Yes No

Foundation Benefit Admin (FBA) - Boon

GroupBOONG Yes No

Fox Everett, Inc. 64069 Yes No

Fraternal Order of Police - Dental

Division (Philadelphia, PA)CX041 No No

Fringe Benefits Coordinators 59204 Yes No

GDS CX036 Yes

Gettysburg CX064 Yes No An Innovative Healthware Services Payer.

GIC Indemnity Plan 80314 Yes No

Gilsbar, Inc. 07205 Yes No

Golden West Dental GWD01 No No

Government Employees Health

Association44054 Yes No

Government Employees Hospital

Association (GEHA)57254 Yes No

Great-West Healthcare 63665 Yes No f.k.a. General American

Great-West Healthcare 80705 Yes No

Group Administrators Ltd. 36338 Yes No

Group and Pension Administrators 48143 Yes No

Group Benefit Administrators 72153

Group Health Coop (Individual &

Family, and Small Business Groups)89070 Yes No Administered by United Concordia

Group Insurance Service Center, Inc 37276 Yes No

Group Link of Indiana CX015 Yes No

Guaranty (DINA) CX090 Yes No

Guardian Life Insurance Company of

America64246 Yes No


Page 6


April 2020


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Real Time Pre


Hamaspik Choice 47738 No

Harrington Health Colonial Dental 59143 No

Hawaii - Mainland Administrators 86066 No

Hawaii Medical Service Association

(HMSA)HMSA1 Yes No

Federal Employee claims cannot be sent

electronically

HCS - Health Claims Service (Boise,

ID)82018 Yes No

Healthchoice OK 71064 Yes No

Health Choice Arizona 62179 Yes No

Health Choice Insurance 46221 Yes No

Health Choice Integrated Care 22100 Yes No

Health Economics Group, Inc. CX039 No No

Health Partners - Jackson, TN 62157 Yes No

Health Plan Services 59140 Yes No

Health Plans Inc. CX055 Yes No

Health Resources Incorporated (HRI) CX019 Yes No

Healthcare Management

Administrators, Inc.HMA01 Yes No

The insured ID number is required. Maximum of

25 procedure lines per Claims. Secondary Claims

cannot be sent electronically. Claims remarks

exceeding 80 bytes in length cannot be sent

electronically.

Healthcomp, Inc. 85729 Yes No

HealthE Exchange Inc. 20356 Yes No

HealthEZ 41178 Yes No

Healthgram, Inc. 56144 Yes No

Healthgram, Inc. 56144 Yes No f.k.a. Primary Physician Care

HealthPartners MN CX009 Yes

MN HealthPartners MN CX010 Yes

Healthplex, Inc. 11271 Yes No

HealthSCOPE Benefits, Inc.(Formerly

CNA Health Partners of Arkansas)71063 Yes No

HealthSmart Benefit Solutions 37272 Yes Nof.k.a. Wells Fargo TPA, Inc., Newnan GA and

Fayetteville, NC

HealthSmart Benefit Solutions 37283 Yes No

HealthSmart Benefit Solutions 87815 Yes No f.k.a. Wells Fargo, TPA, Inc., Charleston, WV

HealthTrans 31172 Yes No a.k.a. Innovante Benefit Administrators

Healthy Michigan Dental HMD01 No No

Ho-Chunk Nation Department of Health 6251 No No

Hometown Health Plans Nevada 88023 Yes No

Hoosier Dental (in Indianapolis,

Indiana)CX015 Yes No

Hotel Employees Restaurant

Employees Health Trust (HERE)91136 Yes No



payer

HSBS Memphis 37224 Yes No f.k.a. Pittman & Associates

HSBS Oklahoma City 37256 Yes No f.k.a. Mutual Assurance Administrators

Humana 73288 Yes No

Humana, Inc. 61101 Yes No

I. E. Shaffer (West Trenton, NJ) 22175 Yes No

IBT - Local 145 Health Service & Ins

PlanCXIBT Yes No

Only for claims with date of service prior to 1-1-16.

Dates of service greater than 12-31-15 should be

sent using payer ID 60054.

iCircle Care of NY 33884 Yes No

IMCare 41600 Yes No f.k.a Itasca Medical Care

Indiana Teamsters Health Benefits

Fund (Indianapolis, IN)35107 Yes No

Formerly known as Local 135 Health Benefits

Fund (Indianapolis, IN)

Inetico 43471 Yes No An Innovative Healthware Services Payer.

Innovante Benefit Administrators 31172 Yes No a.k.a. HealthTrans

Innovation Health 40025 Yes No

Insurance Administrators of America 37279 Yes No

Insurance Design Administrators 13315 Yes No

Insurance Management Services 15688 Yes No

Insurance Systems Inc. 74385 Yes No

Insurers Administrative Corp. 86304 Yes NoPlease visit website prior to submitting Claims:

edihelp.iacusa.com


Page 7


April 2020


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Real Time Pre


Integra Administrative Group (Seaford,

DE)51020 Yes No

Payer ID valid only for Claims with a billing

submission address of 110 S. Shipley Street,

Seaford, DE 19973.

International Brotherhood of

Boilermakers36609 Yes No

Jensen Administrative Services, Inc. CXJAS Yes No

John Morrell Company - AHBPA 38310 Yes No

Joint Benefit Trust CHSJT Yes NoAdministered by Health Services Benefit

Administrators, Inc. (HSBA)

JP Farley Corporation 34136 Yes No

Payer ID valid only for Claims with a billing

submission address of PO Box 458022, Westlake,

OH 44145

Kaiser CX073 Yes No

Kalos Gold Health Plan 61185 Yes No

Kalos Health 40137 Yes No

Kanawha Insurance Co. 57038 Yes No

Keenan Associates 95279 No No

Kemper Benefits 61453 Yes No

Kempton Company 73100 Yes No

Kempton Group Administrators 73100 Yes No

Kentucky Health Co-Op 77894 Yes No

Kentucky Spirit 65030 Yes NoKentucky Medicaid Kentucky Spirit administered

by MCNA

Key Solutions 37323 Yes No

Klais & Company 34145 Yes No

LA BCBS AdvantagePlus Network 53021 Yes No Administered by United Concordia

Land of Lincoln 90096 Yes No

Level LEVEL No

Life Gift Cards 33LGC Yes No

Life Insurance Company of Boston &

New York78140 Yes No

LifeMap Assurance Company RLH01 Yes No

Lifestyle Dental 27005 Yes No

Lifewise Health Plan of Oregon 93093 Yes No

Lincoln Financial Group CX061 Yes No f.k.a. Jefferson Pilot

Lincoln National (WI) 73288 Yes No

Line Construction Benefit Fund LCB01 Yes No

Local 135 Health Benefits Fund

(Indianapolis, IN)35107 Yes No

Local 17 Fund - International

Association of Heat and Frost

Insulators

IAHFI No

Locals 302 & 612 of the Internation

Union of Operating Engineers91136 Yes No



payer

Lockard & Williams CB752 Yes No

Mail Handlers Benefit Plan 25133 Yes No


Consolidated payer ID. Including AFSPA Staff

Plan.

MAMSI CX033 No No

Managed Care Services, LLC 35162 No

Managed Dental Guard GI813 Yes NoOnly for the individual marketplace, not for

Group/SHOP business

MAPFRE PRFRE Yes No

Masonry Institute/Administrative D.C.

No. 1 Welfare FundCX098 Yes No

Mayo Clinic Health Solutions 41154 Yes No

MBA Benefit Administrators, Inc. (Salt

Lake City, UT)83028 Yes No

MBA of Wyoming (Worland, WY) 87065 Yes No

McGregor PACE 31149 Yes No

MCNA Dental 65030 Yes No

Med3000 CMS Safety Net EM284 Yes No

Med3000 CMS Title 19 Reform EM843 Yes No

MED3000 CMS Title 21 EM205 Yes No


Page 8


April 2020


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MEDICA of Minnesota CX026 Yes No

Medical Associate Health Plan

(HEALTH CHOICES)MAHC1 Yes No

Medical Benefits Mutual Administrators

(MedBen)74323 Yes No

Medical Card System (MCS) PRMCS Yes No

Medical Mutual of Ohio 29076 Yes No

Medical Mutual of Ohio CB833 Yes No

Medico Insurance Company 23160 No

Only for Policy Numbers that begin with 000M1D

and claims mailed to PO Box 21660, Eagan, MN

55121

Mercy Care Plan 86052 Yes No

Mercy Maricopa Integrated Care 33628 Yes No

Meritain Health 38232 Yes No f.k.a. Weyco

Meritain Health Minneapolis 41124 Yes No f.k.a. CBSA

Methodist First Choice 23550 Yes No

MetLife 65978 Yes No

Michigan Regional Council of

Carpenters Employees Benefit Plan 38238 Yes No

Michigan UFCW 27401 Yes No

Mid-America Associates, Inc. 37281 Yes No

Mid-American Benefits 22823 Yes No An Innovative Healthware Services Payer.

Midwest Dental Benefits 41101 Yes No

Momentum Insurance Plan 31415 Yes No

Morris Associates 35092 Yes No

Motorola 36111 Yes No

Mountain States Administrative

Services (Tucson, AZ)86040 Yes No

MPEEBT/ MPE Services, Inc. 37233 Yes No

MSA CareGuard 20572 Yes No

MultiFlex Dental (Merchants Benefit) MBAAZ Yes No

Municipal Health Benefit Fund 81883 Yes No

Mutual of Omaha Commercial CX087 Yes No

Mutual of Omaha Insurance Company 71412 Yes No

Mutually Preferred 71412 Yes No

MyDecision 18840 No No

NAA (North America Administrators,

L.P.) (Nashville, TN)65085 Yes No

NABN (Cleveland, OH) 34159 Yes No

Payer ID valid only for Claims with billing

submission address of P.O. Box 94928,

Cleveland, OH 44101-4928 or P.O. Box 89476,

Cleveland, OH 44101-5476.

NAPHCARE, Inc. 58182 No No

National Elevator Industry Benefit Plan

(NEIB)CX045 Yes No

National Pacific of TX (NCFLEX) CX057 Yes No A United Healthcare Payer

National Rural Letter Carrier

Association71412 Yes No

National Telecommunications

Cooperative Association52120 Yes No

Nationwide Employee Benefits 314RV Yes No

Nationwide Health Plans 31417 Yes No

Native Care Health 19191 Yes No

NCAS - Charlotte 75191 Yes No

NCAS - Fairfax, VA 75190 Yes No

Netcare Life and Health Insurance

(NLH) 66055 Yes No

Nevad Dental Benefits NDB01 Yes No

Nevada Health Co-Op 90091 Yes No

New England Dental Administrators 43351 Yes No

Nippon Life Insurance Company of

America81264 Yes No

NNEBT (Northern New England Benefit

Trust)38238 Yes No


Page 9


April 2020


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North American Benefits Network

((Cleveland, OH)34159 Yes No

Payer ID valid only for Claims with billing

submission address of P.O. Box 94928,

Cleveland, OH 44101-4928 or P.O. Box 89476,

Cleveland, OH 44101-5476.

North Broward Hospital District 37314 Yes No

Northern California Pipe Trades Trust

FundsCX099 Yes No

For Dates of Service beginning 1-1-15 please use

payer ID 77777.

Northern Illinois Health Plan 36347 Yes No

Northern Minnesota Dental LX062 Yes No

Northern Nevada Trust Fund 88027 Yes No

Please call (775) 826-7200 to verify if you should

be sending claims to Northern Nevada Trust

Fund.

NorthShore University Health System

Medical Group36364 Yes No

Northwest Dental Services 93525 No No

Northwest Ironworkers Health &

Security Fund91136 Yes No



payer

Northwest Roofers & Employers Health

& Security Trust Fund91136 Yes No



payer

Northwest Suburban IPA 36346 Yes No

Northwest Textile Processors and

Service Trades91136 Yes No



payer

Nova Healthcare Administrators, Inc.

(Grand Island, NY)16644 Yes No

NW International Association of

Machinists (NW IAM)91136 Yes No



payer

NW Plumbers & Pipefitters Health &

Welfare Trust91136 Yes No



payer

Nyhart 37299 Yes No

OH Dental / UHC Dental Government

ProgramsGP133 Yes No f.k.a. Optum Specialty Svcs / Americhoice of NJ

Ohio AFSCME Care Plan AFSOH No

OK DRS DOC 71065 Yes No

Ohio Dept of Corrections (Careworks) J1410 Yes No

OK State Employees & Educators

(EDS)22521 Yes No

Olympus Managed Health Care 65074 Yes No

PA Faculty Health & Welfare CX066 Yes No An Innovative Healthware Services Payer.

PACE Central Iowa 72436 Yes No

PACE Greater New Orlean (NORLIN) 21614 Yes No

PACE Nebraska 35416 Yes No

PACE Southwest Iowa 53534 Yes No

Pace of Southwest Michigan 45114 Yes No

PACE Southeast Michigan 86711 Yes No

Pacific Union CX056 Yes No A United Healthcare Payer

Pacificare Dental and Vision HMO CX060 Yes No A United Healthcare Payer

Pacificare Dental and Vision PPO CX053 Yes No A United Healthcare Payer

PacificSource Administrators 93031 Yes No a.k.a. Select Benefit Administrators

PacificSource Community CXPSC Yes No via Performance Health Technology

PacificSource Health Plans 93029 Yes No

Pan American Life Insurance Group 04218 Yes No

Partners Benefit Group PBGSM Yes No

Partners Health Plan 23213 No

Patient Advocates, LLC 10525 Yes No

PDO 68241 Yes No

PEHP (Public Employees Health

Program)CX080 Yes Yes

Prior to accepting claims electronically PEHP

requires the provider to call EDI Support at 801-

366-7544 or 800-753-7818. Providers should

advise PEHP that they will be submitting their

claims through Change Healthcare Business

Services, Inc UHIN submitter ID HT000158-001.


Page 10


April 2020


*

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Pequot Pharmaceutical 37121 Yes No

Personal Insurance Administrators, Inc 95397 Yes No

Physician Health Partners, Loc PHPMA No

Physicians Health Plan of Northern

Indiana, Inc.12399 Yes No

Physicians Mutual CX068 Yes No

Pinnacle Claims Management, Inc. 24735 Yes No

Planned Administrators, Inc. 37287 Yes No

Prairie States Enterprises, Inc. 36373 Yes No

Preferred Dental Organization 68241 Yes No

Preferred Health Plan of the Carolinas CB404 Yes No

Preferred Health Professionals 31478 Yes No a.k.a. Freedom Network Dental

Preferred One 41147 Yes No

Premier Access Insurance Company CX078 Yes No

Premier Access UT Government CX110 Yes No f.k.a. UT CHIP & UT Medicaid

Premier Dental Plan of MN CX029 Yes No

Prime Health Choice 81502 Yes No

PrimeCare Administrators (PPO) PCA01 Yes No

PrimeWest Health LX049 Yes No

New providers, learn about submitting your first

claim. Please visit https://www.primewest.org/new-

facility-claims

Principal Financial Group 61271 Yes No Payer Only accepts VISION and DENTAL claims.

Priority Health 38217 Yes No

Professional Benefit Administrators,

Inc. (Oak Brook, IL)36331 Yes No

Payer ID is valid only for Claims with billing

submission name, city, and state of Professional

Benefit Administrators, Inc., Oak Brook, IL.

Prominence Health Plan 88029 Yes No

Prudential for Health 68241 Yes No

Prudential HealthCare & Life Ins. Co of

America68241 Yes No

Prudential HealthCare Health

Maintenance Organization68241 Yes No

Prudential HealthCare HMO for Small

Business68241 Yes No

Prudential Healthcare of America Inc. 68241 Yes No

Prudential HealthCare POS for Small


Prudential HealthCare PPO for Small


Puget Sound Electrical Workers

Healthcare Trust (PSEW)91136 Yes No



payer

Quality Care Partners 89461 Yes No An Innovative Healthware Services Payer.

Quality Plan Administrators Inc CX077 Yes No

Quapaw Casino 19191 Yes No

Quapaw Tribal Member Plan 19191 Yes No

Quapaw Tribe Employee Plan 19191 Yes No

Quartz ASO 46571 Yes No

RBMS, LLC 91176 Yes No

Regency Employee Benefits 38221 Yes No

Reliance Standard Life 36088 Yes No

Reliastar 80314 Yes No

ReliaStar (now known as CoreStar

formerly NW National Life)41045 Yes No





Renaissance Life and Health RLHA1 Yes No

Resolve / Solarte Health, Inc CB695 Yes No

Riverside San Bernardino County

Indian Health Inc.50664 Yes No

RMSCO, INC. 16117 Yes No

Rochester Public Schools 41625 Yes No


Page 11


April 2020


*

Real Time Pre


Rural Carrier Benefit Plan 25133 Yes No


Consolidated payer ID. Including NRLCA Staff

Plan.

S&S Health Strategies 31441 Yes No

Safeguard HMO CX048 No No

SafeGuard PPO CX030 Yes No

Sage Technologies 37105 Yes No

f.k.a. Cannon Cochran Management Services,

Inc. Claims with a mailing address of PO Box

17009, Rockford, IL ONLY may be sent

electronically with this payer ID.

Salvation Army 34154 Yes No a.k.a. Chesterfield Resource, Inc.

SAMBA 37259 Yes No

Sana Benefits 50114 Yes No

Sanford Health Plan 91184 Yes No

Scion Dental Commercial SDCOM Yes No

Scion Gateway Health Plan 96938 Yes No

Secure Health Plan of GA 28530

SecureCare Dental 86057 Yes No

Securian 93742 No No

Security Life Insurance Co of America CX092 Yes No

Select Benefit Administrators 93031 Yes No a.k.a. PacificSource Administrators

Select Health CX107 Yes No

SelectCare (Coca Cola) 68241 Yes No

Sele-Dent CX109 Yes No

Self Insured Services Company

(SISCO)CX020 Yes No

Self-Funded Plans, Inc. 34131 Yes No

Self-Insured Dental Services (SIDS) CX076 Yes No



electronically must be credentialed with the payer.

Please ensure you have successfully process one

paper Claims with the payer prior to submitting

your first electronic Claims.

Self-Insured Plans, LLC 36404 Yes No

Senior Network Health - Utica 15682 Yes No

Sheffield, Olson and McQueen 41143 Yes No

Shelter Point Life 81434 Yes No

Sierra Health Services 76342 Yes No A United Healthcare Payer

Significa Benefits Services, Inc. CX046 Yes No f.k.a. Erin Group Admin.

Sinclair Health Plan 84076 Yes No

SingelCare 95456 Yes No

SKYGEN USA SKYGN Yes No

Solstice Benefits, Inc. 76578 Yes No

South Central Preferred - PPO York,

PA (I H S Gateway Payer)23266 Yes No An Innovative Healthware Services Payer.

South FL Community Care Network -

NBHD37314 Yes No

South Point Hotel & Casino 35227 Yes No

Southern Indiana Health Organization

(SIHO)77153 No

Southland Benefit Solutions 26374 Yes No

GROUP NUMBER as printed and displayed on

dental benefit member ID cards is REQUIRED to

be submitted on the claim. Claims will be

REJECTED if the GROUP NUMBER is not

provided. Also, predetermination claims cannot be

accepted at this time and will be REJECTED.

Southwest Service Administrators CX100 Yes No

Southwestern Bell 68241 Yes No

Southwestern Bell Exec 68241 Yes No

Southwestern Bell Exec. - Custom Care 68241 Yes No

Southwestern Bell Exec. -

Southwestern Bell68241 Yes No

Spectrum Admin. 23253 Yes No An Innovative Healthware Services Payer

Standard Ins. Co. (OR Business) 93024 Yes No

Standard Insurance Company (NY) 13411 Yes No


Page 12


April 2020


*

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STAR +Plus Value Added CPPSP Yes Yes




13 and greater.

Star Health CX090 Yes NoUse this payer ID for Dates of Service prior to

June 1, 2010.

StarDent CX090 Yes No

State of Texas Dental Plan 73288 Yes No

Summit America Insurance Services 37301 Yes No

Sun Life and Health Insurance

Company67814 Yes No

f.k.a Genworth Life and Health Insurance

Company (GLHIC) (Formerly GEGLAC)

Superior Dental Care 31117 Yes No

SuperiorSTAR Pregnant Women CPPSW Yes Yes




13 and greater.

Supplemental Coverage ASHC1 Yes No PO Box 2829 Clinton IA 52733

Tall Tree Administrators 88067 Yes No

TDC 73288 Yes No

The Dental Companies 73288 Yes No

The Dental Concern 73288 Yes No

The health Plan of the Upper Ohio

Valley34150 Yes No

The Loomis Company - TPA

Wyomissing, PA (IHS Gateway Payer)23223 Yes No An Innovative Healthware Services Payer.

The Physicians Assurance Corp

(TPAC) /Employee Benefit

Management Corp (EBMC)

CX025 Yes No

Total Dental Administrators CX112 Yes No

Total Plan Concepts 80900 Yes No

Total Senior Care - OLEAN 12268 Yes No x

TPAC/Employee Benefit Management

CorpCX025 Yes No

TR Paul, Inc. 37230 Yes No

Travelers (now MetLife) 65978 Yes No

Travis County Map TCMAP No

TRICARE Dental Program 89070 No Administered by United Concordia effect 5-1-17

Tri-Counties Welfare Trust Fund CHSWT Yes NoAdministered by Health Services Benefit

Administrators, Inc. (HSBA)

Triple-S Salud CBPR1 Yes Yes

Completing this enrollment request will enroll the

provider(s) for

3 transactions – Electronic Claims (837D), Electric

Remittance

Advice (835) and Real Time Eligibility Inquiry and

Response

(270/271) with all 3 payers listed above. Please

ensure you

have an active ERA and Real Time account with

Change

Healthcare prior to submitting the enrollment

request form.

Please feel free to contact your software vendor or

Change

Healthcare to confirm account status.

TriState Benefit Solutions 31144 Yes No

TruAssure ILDTA Yes No

Trusteed Plans Service Corporation 91078 Yes No

Trustmark Insurance Company 61425 Yes No

UltraBenefits, Inc. 41206 No

UMR - Cincinnati 33108 Yes No f.k.a. United Medical Resources

UMR - Harrington 75196 Yes No f.k.a. Harrington Benefit Services (Westerville)

UMR - Harrington 95266 Yes No f.k.a. Harrington Benefit Services (Columbus)

UMR - Lexington 37237 Yes No f.k.a. Commonwealth Administrative Group

UMR - Onalaska 79480 Yes No f.k.a. Midwest Security of WI


Page 13


April 2020


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Real Time Pre


UMR - San Antonio 74223 Yes Nof.k.a. Benefit Planners Inc., UICI Administrators -

State of Nevada

UMR - Wausau/UHIS 39026 Yes Nof.k.a. Fiserv Health - Wausau Benefits/Benesight,

Employers Insurance of Wisconsin

UMWA Health & Retirement Funds 52180 No

UNICARE 80314 Yes No

Unified Group Services 35198 Yes No

Uniform Medical Plan 75243 Yes Nof.k.a. Uniform Medical Plan / Harrington Benefit

Services

Union Security Insurance Company 70408 Yes No PO Box 2877, Clinton, IA 52733

United Concordia - Dental Plus CX013 Yes No Y Y

United Concordia - Fee for Service CX007 Yes No Y Y Administered by United Concordia

United Food & Comm Workers union &

Employers Midwest Health Benefit

Funds

36659 Yes No

United HealthCare Insurance Company

- Student Insurance74227 Yes No

A United Healthcare Payer. Payer ID only valid if

the P.O. Box on the Health ID Card matches one

of the following P.O. Boxes: P.O. Box 809024,

809025, 809026, 809027, 809035, 809036,

809066, 809067, 809079, or 809081 Dallas, Tax

75380-9025.

United of Omaha 71412 Yes No

United States Life Insurance Company 13545 Yes No f.k.a. American General

UnitedHealthcare Dental 52133 NoFormerly OptumHealth Dental, Dental Benefit

Providers/DBP and DBP of California

Unity Health Insurance Corp 66705 Yes NoOnly claims for Oral Surgery, TMJ or Accidents

can be sent electronically to this payer ID.

University of Missouri 25133 Yes NoFormerly payer ID 87043. Now part of Coventry


UPMC Health Plan 23281 Yes No

Upper Peninsula Health Group (TPA) 37324 Yes No

US Benefits Inc. 93092 Yes No

US Life Ins. Co. 70106 Yes NoClaims mailing address of PO Box 12009,

Cheshire, CT

VA Fee Basis Programs 12116 Yes No

Valley Baptist Health Plan 89070 Yes Administered by United Concordia

Valor Health Plan 43259 Yes No

Vantage Health Plan 72128 Yes No

Varian Health Care Plan 68241 Yes No

Verity National Group 75256 Yes No

VieCare - LIFE Armstrong 25922 Yes No

VieCare - LIFE Butler 25293 Yes No

VieCare Life Beaver and Life Lawrence

Counties25924 Yes No

Viva Health Medicare Plus 63114 Yes No

Voluntary Benefits Plan 70106 Yes NoClaims mailing address of PO Box 12009,

Cheshire, CT

Volusia Health Network 59266 Yes No

Washington State Council of County &

City Employees (WSCCCE)91136 Yes No



payer

Waterstone Benefit Administrators

(Oklahoma Providers)73155 Yes No

Web TPA, Inc of TX 59332 Yes No

Wells Fargo TPA, Inc (Charleston, WV) 87815 Yes No f.k.a. Acordia National

Wells Fargo TPA, Inc. (Newnan, GA

and Fayetteville, NC)37272 Yes No f.k.a. JSL Administrators

Western Grower's Assurance Trust 24735 Yes No

Western Grower's Insurance Company 24735 Yes No

WestLake Financial Group, Inc.

(Buffalo Grove, IL)90560 Yes No

Wichita and Affiliated Tribes 19191 Yes No


Page 14


April 2020


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Real Time Pre


Willamette Valley CXWVC Yes No via Performance Health Technology

William C. Earhart 93050 No No

WilsonMcShane R7002 No No

Worksite Benefit Services, LLC 20333 Yes No

Wyoming PACE 98543 No No

Zenith Administrators R7001 No No

ACS Benefit Services, Inc. 61474 Yes No ACS Branded Dental Product

Alameda Alliance CX083 No Admin by LIBERTY Dental Plan

Anthem Health Plans - HMOD & HMOG CX083 Yes No Admin by LIBERTY Dental Plan

Anthem Health Plans of Kentucky -

OSB High & LowCX083 Yes No Admin by LIBERTY Dental Plan

Anthem Health Plans of Kentucky -

PPOB & PPOD CX083 Yes No Admin by LIBERTY Dental Plan

Anthem Health Plans of Virginia - OSB

High & Low CX083 Yes No Admin by LIBERTY Dental Plan

Anthem Health Plans of Virginia -

PPOB & PPOD CX083 Yes No Admin by LIBERTY Dental Plan

Anthem HMO Colorado - HMO-B CX083 Yes No Admin by LIBERTY Dental Plan

Anthem Insurance - OSB High & Low CX083 Yes No Admin by LIBERTY Dental Plan

Anthem Insurance - PPOB & PPOD CX083 Yes No Admin by LIBERTY Dental Plan

Blue Cross Blue Shield Association -

FEP DentalBCAFD Yes No

Blue Cross Blue Shield of North

Carolina61474 Yes No Dental Blue Select Product


Carolina61472 Yes No EHB Pediatric Dental Claims


Carolina61472 Yes No Federal Employee Claims.


Carolina61473 Yes No Dental Blue Product

Blue Cross Blue Shield of Wisconsin -

PPOD CX083 Yes No Admin by LIBERTY Dental Plan

Blue Cross Dental CBMNU Yes No Non FEP claims

Blue Cross of California - OSB High &

Low CX083 Yes No Admin by LIBERTY Dental Plan

Blue Cross of California - Plan SS10 &

SS20 CX083 Yes No Admin by LIBERTY Dental Plan

Blue Cross of California - PPOA CX083 Yes No Admin by LIBERTY Dental Plan

Cal Optimal -OneCare CX083 Yes No Admin by LIBERTY Dental Plan

Care 1st Health Plan Medicare

Advantage CX083 Yes No Admin by LIBERTY Dental Plan

Care 1st PHP LA & San Bernadino

County CX083 Yes No Admin by LIBERTY Dental Plan

Community Insurance - HMOA & PPOB CX083 Yes No Admin by LIBERTY Dental Plan

Community Insurance - PPOD & PPOF CX083 Yes No Admin by LIBERTY Dental Plan

Dearborn National 36123 No No

EasyChoice Health Plan CX083 Yes No Admin by LIBERTY Dental Plan

EmpireHealthChoice Assurance - OSB

Low & PPOB CX083 Yes No Admin by LIBERTY Dental Plan

EmpireHealthChoice HMO CX083 Yes No Admin by LIBERTY Dental Plan

Golden State Health Plan CX083 Yes No Admin by LIBERTY Dental Plan

Health Net 21 - LA & Sacramento CX083 Yes No Admin by LIBERTY Dental Plan

Health Net Healthy Families A, B & C CX083 Yes No Admin by LIBERTY Dental Plan

Health Net Los Angeles PHP CX083 Yes No Admin by LIBERTY Dental Plan

Health Net Sacramento GMC CX083 Yes No Admin by LIBERTY Dental Plan

Healthy Alliance Life Insurance - PPOB CX083 Yes No Admin by LIBERTY Dental Plan

Horizon Healthcare Dental Services 22099 Yes No

LA Care Health Plan CX083 Yes No Admin by LIBERTY Dental Plan

Liberty Dental Plan CX083 Yes No

MD Care Health Plan CX083 Yes No Admin by LIBERTY Dental Plan

MGM Resorts International CX083 Yes No Admin by LIBERTY Dental Plan

Molina HealthCare CX083 Yes No Admin by LIBERTY Dental Plan

NorthStar Administrators 47570 Yes No


Page 15


April 2020


*

Real Time Pre


Ohana Health Plan CX083 Yes No Admin by LIBERTY Dental Plan

Ozark Health Plan CX083 Yes No Admin by LIBERTY Dental Plan

Physicians United Plan-PUP CX083 Yes No Admin by LIBERTY Dental Plan

Premera Blue Cross 47570 Yes No

Rocky Mountain Hospital & Medical

Service - OSB High & High CX083 Yes No Admin by LIBERTY Dental Plan

Rocky Mountain Life Dental 84102 Yes No

Sands Bethworks Gaming CX083 Yes No Admin by LIBERTY Dental Plan

Santa Clara Family Health Plan CX083 Yes No Admin by LIBERTY Dental Plan

Venetian CX083 Yes No Admin by LIBERTY Dental Plan

Wellcare CX083 Yes No Admin by LIBERTY Dental Plan

WellPoint CX083 Yes No Admin by LIBERTY Dental Plan

Blue Cross of Alaska and Washington 47570 Yes No

AL Blue Cross of Alabama CBAL1 Yes No

AZ Arizona Blue Cross Blue Shield 53589 Yes No

Anthem Blue Cross 47198 Yes No f.k.a. Blue Cross of California; Wellpoint

CA CA Blue Shield 94036 No Non FEP Claims Only

CO Blue Cross of Colorado 84099 Yes No

CO Trigon Blue Cross Blue Shield -

Colorado Dental Office84103 Yes No

Claims Mailing Address: Trigon Dental Admin,

555 Middle Creek Parkway, MS 400, Colorado

Springs, CO 80921.

CTBlue Cross Blue Shield OH/KY

(Anthem)84105 Yes No

CT Blue Care Family Plan (BCBS of CT) 00700 Yes No

FL Florida Blue FEP CBFLF No Only FEP claims

GA Georgia BCBS CBGA1 Yes No

IA Blue Cross of Iowa "Wellmark" CBIA2 Yes Yes

IA Blue Cross of Iowa (FEP Claims Only) CBIA1 Yes Yes FEP Claims only

ID Blue Cross of Idaho CBID1 Yes Yes

ID Blue Shield of Idaho CBID2 Yes No

IL Blue Cross of Illinois CB621 Yes No

KYBlue Cross Blue Shield OH/KY


LA Blue Cross Blue Shield of Louisiana 23739 Yes NoPayer requires providers be tied to our submitter

ID of P0003784

MA Blue Cross of Massachusetts CBMA1 Yes No

MI Blue Cross Blue Shield of Michigan CBMI1 Yes No

MN Blue Cross Blue Shield of Minnesota CBMN1 NoUse for claims mailed to PO Box 64338, St. Paul,

MN 55164-0338

MOBlue Cross Blue Shield of Kansas City

MO47171 Yes No

EDI enrollment is no longer required by ASK

however the payer requires each provider register

with them.

MS Blue Cross of Mississippi CBMS1 Yes Yes

MT Blue Cross Blue Shield of Montana CBMT1 Yes No

NDBlue Cross of North Dakota (ND Dental

Services)CX004 Yes Yes Administered by United Concordia

NE Blue Cross of Nebraska CBNE1 No No

NM Blue Cross of New Mexico CBNM1 No No

NV Blue Cross of Nevada 84101 Yes NoNo FEP Claims. Please send FEP Claims on

paper or use Payer ID 06126.

NY BCBS of Rochester New York CBNYR No No

NY BCBS of Western NY CBNYW Yes No

NY BS of Northeastern NY CBNYE Yes No



with them.

NY Empire Blue Cross Blue Shield CBNY1 No No FEP claims may not be sent electronically.

NY Healthnow of Northeastern NY CBNYE Yes Yes

NY Healthnow of Western NY CBNYW Yes Yes



with them.

OHBlue Cross Blue Shield OH/KY


OK Blue Cross blue Shield of Oklahoma SB840 No

OR Regence OR BC/BS CB850 Yes No

PA Pennsylvania Blue Shield CB865 Yes No


Page 16


April 2020


*

Real Time Pre


PA Pennsylvania Blue Shield Dental Plus CBPA2 Yes No

RI South Carolina BCBS 38520 Yes No

SD Blue Cross Blue Shield of South Dakota

"Wellmark"CBSD1 Yes Yes

TN Blue Cross of Tennessee CBTN1 Yes Yes

TX Blue Cross of Texas CB900 Yes No

UT Regence UT BCBS CBUT1 Yes No

UT Regence UT BCBS FEP CBUTF Yes No

VA Trigon VA - BCBS (Dental) CB923 Yes No

WA Blue Cross of Alaska and Washington 47570 Yes No

WA Regence Blue Shield 93200 Yes No

WA Regence Blue Shield FEP 93200 Yes No

WA Regence Northwest Health 93200 Yes No

WI WI - BCBS (Dental) CB950 Yes No

WY Blue Cross Blue Shield Wyoming CBWY1 Yes Yes Administered by United Concordia

AL Delta Dental AL (DDIC) DDAL1 No No

Delta Dental Insurance Co. (DDIC) - All

Payers94276 No No

DeltaCare USA Claims DDCA2 Yes No f.k.a. PMI

Northeast Delta Dental (ME, NH, VT) 02027 Yes No

AR Delta Dental of Arkansas CDAR1 Yes No

AZ Delta Dental of Arizona 86027 Yes No Y Y

CA Delta Dental of California - CA00

Claims Office77777 Yes No

CA Delta Dental of California/Tricare

Retiree DentalCDCA1 Yes No

CO Delta Dental of Colorado 84056 Yes No

DC Delta Dental of Washington DC 52147 Yes No

DE Delta Dental of Delaware 51022 Yes No

FL Delta Dental of Florida (DDIC) DDFL1 No No

GA Delta Dental of Georgia (DDIC) DDGA1 No No

IA Delta Dental of Iowa CDIA1 Yes No Y Y

ID Delta Dental of Idaho 82029 Yes No

IL Delta Dental of Illinois Group Plans 05030 Yes No Y Y

IL Delta Dental of Illinois Individual Plan IDIND Yes No

IN Delta Dental of Indiana CDIN1 Yes No

KS Delta Dental of Kansas CDKS1 Yes No

KY Delta Dental of Kentucky CDKY1 Yes No

LA Delta Dental of Louisiana (DDIC) DDLA1 No No

MA Delta Dental Massachusetts 04614 No No

MDDelta Dental of Maryland and

Pennsylvania23166 Yes No

MI Delta Dental of Michigan CDMI0 Yes No

MN Delta Dental of Minnesota CDMN1 Yes No

MO Delta Dental of Missouri 43090 Yes No Y Y

MS Delta Dental of Mississippi (DDIC) DDMS1 No No

MT Delta Dental of Montana (DDIC) DDMT1 No No

NC Delta Dental of North Carolina 56101 Yes No

ND Delta Dental of North Dakota CDND1 Yes No

NE Delta Dental of Nebraska CDNE1 Yes No

NJ Delta Dental of New Jersey 22189 Yes No

NJ NJ Delta DHMO 22267 No

NM Delta Dental of New Mexico 85022 Yes No

NV Delta Dental of Nevada (DDIC) DDNV1 No No

NY Delta Dental of New York 11198 Yes No

OH Delta Dental of Ohio CDOH1 Yes No

OK Delta Dental of Oklahoma CDOK1 Yes No

OR Delta Dental of Oregon (Oregon Dental

Service)CDOR1 Yes No

PADelta Dental of Maryland and

Pennsylvania23166 Yes No

PR Delta Dental Puerto Rico 66043 Yes No

RI Altus 50503 Yes No

RI Delta Dental of Rhode Island 05029 Yes No

SC Delta Dental of South Carolina 43091 Yes No Y Y

SD Delta Dental of South Dakota 54097 Yes No


Page 17


April 2020


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Real Time Pre


TN Delta Dental of Tennessee CDTN1 Yes No

TX Delta Dental of Texas (DDIC) DDTX1 No No

UT Delta Dental of Utah (DDIC) DDUT1 No No

VA Delta Dental of Virginia CDVA1 No No

WA Delta Dental of Washington 91062 Yes No Y f.k.a. Washington Dental Service

WI Delta Dental of Wisconsin 39069 Yes No Y Y

WV Delta Dental of West Virginia 31096 Yes No

A&D Charitable Foundation, Inc. (dba

GreatLakes PACE)39640 No

DentaQuest - Government Plans CX014 No

Eddy SeniorCare 08754 No

Elderwood Health 03964 No

Fresno PACE 99660 No

Life Circles PACE 71498 No

Next Level Health Partners, LLC 69821 No

PACE CNY 70454 No

San Diego PACE 96400 No

SCION Dental SCION No

U. S. Virgin Island Medicaid CUSVI No

Valir PACE 64009 No

Via Christi HOPE 48123 No

Medicaid of Alaska CKAK1 Yes

AL Medicaid of Alabama CKAL1 Yes

AR Arkansas Medicare Advantage ARCMS No

AR Medicaid of Arkansas CKAR1 No

AZ Arizona Medicaid CKAZ1 No

Please visit

http://www.azahcccs.gov/commercial/ProviderRegi

stration/registration.aspx for provider registration

information prior to submitting claims.

AZ Department of Economic Security DESAZ No

CA Dental Transformation Initiative (DTI) DTCA7 No

There is no enrollment for claims submission. To

become a participating provider an office must fill

out a form

(http://www.dhcs.ca.gov/provgovpart/denti-

cal/Documents/Safety%20Net%20Clinic%20Opt-

In%20Form(fin)Edits.docx) and email it to

[email protected]

CA Denti-Cal / Medicaid of California 94146 No

CA Medi-Cal / Medicaid of Californai 57016 Yes Claims sent in the instiutuional format 837I

CO Medicaid of Colorado CKCO1 No

CT Medicaid of Connecticut CKCT1 No

DC District of Columbia Medicaid CKDC1 Yes

DE Delaware Medicaid CKDE1 Yes

FL DentaQuest - Government Plans CX052 No

FL Florida Medicaid CKFL1 Yes

FL Medicaid of Florida CKFL1 Yes

GA Medicaid of Georgia CKGA1 No

IA Delta Dental of Iowa Medicaid Program CDIAM No Y Y

IA Medicaid of Iowa CKIA1 Yes

ID DentaQuest - Government Plans CKID1 No

IL DentaQuest - Government Plans CKIL1 No

IN Indiana Children's Special Healthcare CX070 No

IN Medicaid of Indiana CKIN1 No

KS Medicaid of Kansas CKKS1 No

KY DentaQuest - Government Plans CKKY3 No

KY Medicaid of Kentucky CKKY1 Yes

LA Medicaid of Louisiana 65030 No

MA Health Safety Net CKHSN Yes

MA Massachusetts Health Program CKMA1 NoPlease place MASS Health or MA Medicaid or

MASS Medicaid in the carrier name field.

MD DentaQuest - Government Plans CKMD1 No

ME Maine Medicaid for FQHC CKMEH Yes

ME Medicaid of Maine CKME1 Yes

MI BCBS MI Medicare Advantage BBMDQ No

MI Medicaid of Michigan CKMI1 No

MN Medicaid of Minnesota CKMN1 Yes

MO Medicaid of Missouri CKMO1 No


Page 18


April 2020


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MS Medicaid of Mississippi CKMS1 Yes

MT Medicaid of Montana CKMT1 No

NC Medicaid of North Carolina CKNC1 No

ND North Dakota Medicaid CKND1 No



electronically must submit their ND Medicaid

assigned provider ID(s) within the Claims.

Provider IDs are always 5 digits long and begin

with the number 4.

NE Medicaid of Nebraska CKNE1 Yes

NH Medicaid of New Hampshire CKNH1 No

NJ Medicaid of New Jersey CKNJ1 Yes

NM New Mexico Medicaid CKNM1 Yes

NV Medicaid of Nevada CKNV1 Yes

NY Medicaid of New York CKNY1 Yes

NY Medicaid of New York (Dental Clinics

Only)CKNY2 Yes

NY NYS DOH UCP 14142 YesDept of Health AIDS Drug Assistance Program

(ADAP) - UCP is Uninsured Care Program

OH CareSource CKOH2 No

OH Medicaid of Ohio CKOH1 No

OK Medicaid of Oklahoma CKOK1 No

OR Medicaid of Oregon CKOR1 Yes

PA Medicaid of Pennsylvania CKPA1 No

PR Triple-S Medicaid Advantage PRADV No

RI Medicaid of Rhode Island CKRI1 No

SC DentaQuest - Government Plans CKSC1 No

SD South Dakota Medicaid CKSD1 NoSouth Dakota's Meddicaid contractor is South

Dekota Delta

TN DentaQuest - Government Plans 62154 No

TX Cook Children's Dental CPPCC No

TX Medicaid of Texas CKTX1 No

UT Medicaid of Utah CKUT1 No

VA DentaQuest - Government Plans CKVA1 No

VT Medicaid of Vermont CKVT1 Yes

WA Medicaid of Washington CKWA1 Yes

WI Medicaid of Wisconsin CKWI1 No

WI Wisconsin Medicare Advantage WIMAN No

WV Aetna Better Health of WV 128WV No

WV Medicaid of West Virginia CKWV1 No

WY Delta Dental of Wyoming CDWY1 Yes No

WY Medicaid of Wyoming CKWY1 Yes


Page 19