220 Burnham Street South Windsor, CT 06074 Vox 888 · PDF file220 Burnham Street South...
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220 Burnham Street ● South Windsor, CT 06074 Vox 888-255-7293 ● Fax 860-289-0055 HOW TO UN-ENROLL DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) Page 1 of 1 11-12-15: dlv 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 a Change Healthcare Dental Connect account need only ignore the ERA option when logging into the DC. 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 un- enrollment in the far right column next to each of your payers. CONTACT PHONE NUMBER Change Healthcare Dental Provider Enrollment 888-255-7293
Transcript of 220 Burnham Street South Windsor, CT 06074 Vox 888 · PDF file220 Burnham Street South...
220 Burnham Street ● South Windsor, CT 06074 Vox 888-255-7293 ● Fax 860-289-0055
HOW TO UN-ENROLL
DENTAL ELECTRONIC REMITTANCE ADVICE (ERA)
Page 1 of 1
11-12-15: dlv
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 a ChangeHealthcare Dental Connect account need only
ignore the ERA option when logging into the DC.
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 un-
enrollment in the far right column next to each of
your payers.
CONTACT PHONE NUMBER Change Healthcare Dental Provider Enrollment 888-255-7293
Change Healthcare Dental Payer List
4/7/2017
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Payer ID ERA Un-Enrollment Process
AARP AARP1 Email request to dentalenrollment@Change Healthcare.com. Included provider name and Tax ID.
Advantica Benefits 43168 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Adventist Health System West - Roseville, CA 95340 Email request to dentalenrollment@Change Healthcare.com. 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.
Aetna Medicare EPO/PPO Dental 18014 Email [email protected] stating your request. Be certain to include provider tax ID and name
AGC International Union of Operating Engineers Local 701
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
AK United Food and Commercial Workers (AK UFCW)
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Alask Carpenters
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Alaska Hotel Employees, Restaurant & Camp Employees (AK HERE)
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Alaska Laborers Construction Industry Health & Security Trust
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Alaska Machinists Health and Welfare Trust
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Alaska Pipe Trades U A Local 375
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
3
Payer ID ERA Un-Enrollment Process
Alaska Public Employees Association (APEA/JESS Health & WelfareTrust)
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Allied Metal Crafts Security Plan Trust Fund
91136 Email request to dentalenrollment@Change Healthcare.com. 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
Association Benefit Plan 25133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Assurant Health (IM & GROUP FULLY - INSURED ) 39065If 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.
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Payer ID ERA Un-Enrollment Process
Benefit Inc. R7003
Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request.
Phone: 800-328-1188Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Benefit Systems & Services, Inc. (BSSI) 36342 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Benefits Administration Corporation, Inc. 44357 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Blue Care Family Plan GWD01
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/
Boon Administrative Services, Inc. BOONG Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
California State Government Programs CPPCA Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
CareFirst, Inc. Maryland BCBS 00580 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Cement Masons and Plasterers Health & Welfare Trust
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Central Reserve Life 34097 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
CHAMPVA - HAC 84147 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
CIGNA 62308 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
CNIC Health Solutions Inc. 37227 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
Community Health Electronic Claims/CHEC/webTPA 75261 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Connecticut General (CIGNA) 62308 Email request to dentalenrollment@Change Healthcare.com. 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.
CoreSource Little Rock 75136 If a provider wishes to discontinue receiving ERAs from CoreSource call Coresource helpdesk at 1-866-590-2868.
CoreSource MD PA IL 35182 If a provider wishes to discontinue receiving ERAs from CoreSource call Coresource helpdesk at 1-866-590-2868.
CoreSource NC IN 35180 If a provider wishes to discontinue receiving ERAs from CoreSource NC IN email request to [email protected]
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Payer ID ERA Un-Enrollment Process
Coventry Dental CX049 Email [email protected] stating your request. Be certain to include provider tax ID and name
Coventry Health Care Carelink 25133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Coventry Health Care Carelink Medicaid 25133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Coventry Health Care National Network 25133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Coventry Healthcare of Georgia 128FL Contact Coventry Helthcare of Florida
Coventry Missouri 25133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
CTI Administrators 42141 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Dart Management Corp. 06172If 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 dentalenrollment@Change Healthcare.com
DeCare Dental Health Insurance 07035
Contact DeCare Networks Professional Services department either via phone or in writing stating your request.
Phone: 800-658-4187Fax: 800-658-4186
Mail: PO Box 1175, Minneapolis, MN 55440-1175
UnitedHealthcare Dental 52133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Dental Select CX093 Email request to dentalenrollment@Change Healthcare.com. 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.
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Payer ID ERA Un-Enrollment Process
District 9 Machinists Welfare Trust MWELT Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
DQ/Emblem (Emblem Health Medicaid) EMBDQ Submit new enrollment form with reason for submission denoted as cancel
Electrical Workers Welfare Trust 52611 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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 dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
EQUICOR 62308 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
Evergreen Health Co-Op 93240 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
ExclusiCare 71412 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Fairbanks North Star Borough
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Fairbanks North Star Borough School District Plan A (FNSBSD)
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Fairbanks North Star Borough School District Plan B (FNSBSD)
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
First Reliance Standard Life Ins. Co. (NY Business) 13317 No un-enrollment is required by the payer. Paper EOPs can be obtained at http://www.ameritas.com/index.htm
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Payer ID ERA Un-Enrollment Process
Flex Compensation R7004
Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request.
Phone: 800-328-1188Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Florida Combined Life CBFLU Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Foreign Service Benefit Plan 25133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Foundation Benefit Admin (FBA) - Boon Group BOONG Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
GDS CX036 Email [email protected] stating your request. Be certain to include provider tax ID and name
GIC Indemnity Plan 80314
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/
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Payer ID ERA Un-Enrollment Process
Golden West Dental GWD01
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/
Government Employees Hospital Association (GEHA) 44054 If a provider wishes to discontinue receiving ERAs from GEHA email request to [email protected].
Great-West Healthcare 80705 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Group Benefit Administrators 72153If 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 dentalenrollment@Change Healthcare.com
Guardian Life Insurance Company of America 64246 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Hawaii - Mainland Administrators 86066 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
Hawaii Medical Service Association (HMSA) HMSA1 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Health Choice Arizona 62179 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Health Choice Generations 62180 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Health Choice Insurance 46221 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Health Choice Integrated Care 22100 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Health Choice Utah 45399 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
HealthPartners MN CX009 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 dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
HealthSmart Benefit Solutions 37272 Email request to dentalenrollment@Change Healthcare.com. 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]
Hotel Employees Restaurant Employees Health Trust (HERE)
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
Humana, Inc. 61101 • Email request to dentalenrollment@Change Healthcare.com.• Include provider name and Tax ID.
Insurance Program Managers Group (IPMG) 36342 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
John Alden Life Insurance Co. 41099If 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.
Kaiser CX073 Email [email protected] stating your request. Be certain to include provider tax ID and name
LA BCBS AdvantagePlus Network 53021 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Locals 302 & 612 of the Internation Union of Operating Engineers
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
Mail Handlers Benefit Plan 25133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
MAPFRE PRFRE Contact payer at 787-250-6500
Mayo Clinic Health Solutions 41154 Provider must call MMSI Customer Service at 800-533-1564 and make a request.
MBS 56205 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
MED3000 CMS Early Steps EM350 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Med3000 CMS Title 19 Reform EM843 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
Med3000 CMS Title 21 EM205 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
MedCost Benefit Services 56205 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
MEDICA of Minnesota CX026
Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request.
Phone: 800-328-1188Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Medical Benefits Mutual Administrators (MedBen) 74323 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Medical Card System (MCS) PRMCS Contact payer at 888-758-1616
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.
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Payer ID ERA Un-Enrollment Process
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 dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Mercy Care Plan 86052 If a provider wishes to discontinue receiving ERAs from Mercy Care Plan call 602-263-3000 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 866-602-1979
MetLife 65978 Please visit caqh.org
Michigan UFCW 27401 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
Municipal Health Benefit Fund 81883 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Mutual of Omaha Commercial CX087If 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 dentalenrollment@Change Healthcare.com
Mutual of Omaha Insurance Company 71412 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Mutually Preferred 71412 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
National Elevator Industry Benefit Plan (NEIB) CX045 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
National Rural Letter Carrier Association 71412 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
20
Payer ID ERA Un-Enrollment Process
New England Dental Administrators 43351 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Nippon Life Insurance Company of America 81264 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Northwest Ironworkers Health & Security Fund
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Northwest Roofers & Employers Health & Security Trust Fund
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Northwest Textile Processors and Service Trades
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
NW International Association of Machinists (NW IAM)
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
NW Plumbers & Pipefitters Health & Welfare Trust
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
OH Dental / UHC Dental Government Programs GP133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Ohio Dept of Corrections (Careworks) J1410 No un-enrollment is available. Jopari CareWorks requires claims submitted EDI (837D) to have remits delivered EDI (835).
OK State Employees & Educators (EDS) 22521
Providers should submit a new agreement with the Reason for Submission denoted as Cancel Enrollment to the below.
In Network providers fax to 405-717-8977Non Network providers email to [email protected].
PacificSource Administrators 93031 Providers who wish to discontinue receiving ERAs need to call PacificSource Health Plans and make the request. 800-624-6052
PacificSource Health Plans 93029 Providers who wish to discontinue receiving ERAs need to call PacificSource Health Plans and make the request. 800-624-6052
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Payer ID ERA Un-Enrollment Process
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
HSBS Memphis 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 dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Preferred One 41147 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
PrimeWest Health LX049Paper 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 dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Priority Health 38217 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Puget Sound Electrical Workers Healthcare Trust (PSEW)
91136 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Reliance Standard Life 36088 No un-enrollment is required by the payer. Paper EOPs can be obtained at http://www.ameritas.com/index.htm
Reliastar 80314
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/
24
Payer ID ERA Un-Enrollment Process
Renaissance Life and Health RLHA1If 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 dentalenrollment@Change Healthcare.com
Reserve National Insurance Company 73066 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Rural Carrier Benefit Plan 25133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
SafeGuard PPO CX030 Please visit caqh.org
Secure Health Plan of GA 28530 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Securian 93742
Contact DeCare Networks Professional Services department either via phone or in writing stating your request.
Phone: 800-658-4187Fax: 800-658-4186
Mail: PO Box 1175, Minneapolis, MN 55440-1175
25
Payer ID ERA Un-Enrollment Process
Select Benefit Administrators 93031 Providers who wish to discontinue receiving ERAs need to call PacificSource Health Plans and make the request. 800-624-6052
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.
Sierra Health Services 76342 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Southern Benefits Administration Inc 38242 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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
26
Payer ID ERA Un-Enrollment Process
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 39065If 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 dentalenrollment@Change Healthcare.com. 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.
27
Payer ID ERA Un-Enrollment Process
TransChoice - Key Benefit Administrators 37284 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Triple-S Salud CBPR1 Contact payer at [email protected]
UMR - Wausau/UHIS 39026 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
UMWA Health & Retirement Funds 52180 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
UNICARE 80314
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/
United Concordia - Dental Plus CX013 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
28
Payer ID ERA Un-Enrollment Process
United Concordia - Fee for Service CX007 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
United HealthCare Insurance Company - Student Insurance 74227 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
United of Omaha 71412 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
University of Missouri 25133 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
UPMC Health Plan 23281 Email request to dentalenrollment@Change Healthcare.com. 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 Change Healthcare at 860-289-0055.
29
Payer ID ERA Un-Enrollment Process
Washington State Council of County & City Employees (WSCCCE)
91136 Email request to dentalenrollment@Change Healthcare.com. 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 dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
WilsonMcShane R7002
Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request.
Phone: 800-328-1188Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Dearborn National
36123 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
30
Payer ID ERA Un-Enrollment Process
Horizon Healthcare Dental Services 22099If 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.
Blue Cross of Arkansas CBAR1 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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Payer ID ERA Un-Enrollment Process
Arizona Blue Cross Blue Shield 53589 Submit new form denoting the request as a cancellation.
Anthem Blue Cross 47198
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 Colorado 84099
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
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/
Trigon Blue Cross Blue Shield - Colorado Dental Office 84103
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 Blue Shield OH/KY (Anthem) 84105
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/
32
Payer ID ERA Un-Enrollment Process
Blue Care Family Plan (BCBS of CT) 00700
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 Blue Shield Delaware Fully - Insured Dental Group Business 53287 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Georgia BCBS CBGA1
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 Iowa CBIA2If 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 Cross of Iowa CBIA1If 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.
33
Payer ID ERA Un-Enrollment Process
Blue Cross of Illinois CB621 Email request to dentalenrollment@Change Healthcare.com. 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.
Blue Cross Blue Shield OH/KY (Anthem) 84105
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 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 dentalenrollment@Change Healthcare.com. Include the provider's name, Tax ID and NPI.
Blue Cross Blue Shield of Michigan CBMI1
Email request to dentalenrollment@Change Healthcare.com. 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].
34
Payer ID ERA Un-Enrollment Process
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 800-826-4068.
Blue Cross Blue Shield of Montana CBMT1 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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 dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
35
Payer ID ERA Un-Enrollment Process
Blue Cross of Nevada 84101
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/
Empire Blue Cross Blue Shield CBNY1
Contact DeCare Networks Professional Services department either via phone or in writing stating your request.
Phone: 800-658-4187Fax: 800-658-4186
Mail: PO Box 1175, Minneapolis, MN 55440-1175
Blue Cross Blue Shield OH/KY (Anthem) 84105
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 blue Shield of Oklahoma SB840 Email request to dentalenrollment@Change Healthcare.com. 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 dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
36
Payer ID ERA Un-Enrollment Process
Pennsylvania Blue Shield Dental Plus
CBPA2 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Blue Cross of Rhode Island CB870
Non FEP: Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID. FEP: 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 Change Healthcare 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 803-264-4730 for additional information.
Blue Cross of Texas CB900 Email request to dentalenrollment@Change Healthcare.com. 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.
37
Payer ID ERA Un-Enrollment Process
Trigon VA - BCBS (Dental) CB923
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 Alaska and Washington 47570 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements.
Regence Blue Shield 93200 No un-enrollment is necessary at Providers will continue to be able to see their remits in the Regence Provider Center websites
WI - BCBS (Dental) CB950
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/
Delta Dental Insurance Co. (DDIC) - All Payers 94276 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
DeltaCare USA Claims DDCA2 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
38
Payer ID ERA Un-Enrollment Process
DeltaCare USA Encounters DDCA3 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Northeast Delta Dental (ME, NH, VT) 02027 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Delta Dental of Arkansas CDAR1If 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 dentalenrollment@Change Healthcare.com
Delta Dental of Arizona 86027If 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 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Delta Dental of California/Tricare Retiree Dental CDCA1 If a provider wishes to discontinue receiving ERAs from Delta Dental of California/Tricare Retiree Program email request to dentalenrollment@Change Healthcare.com
39
Payer ID ERA Un-Enrollment Process
Delta Dental of Washington DC 52147 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Delta Dental of Delaware 51022 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
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
orEmail [email protected]
Delta Dental of Idaho 82029Any 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 05030Providers 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 CDIN1If 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 dentalenrollment@Change Healthcare.com
40
Payer ID ERA Un-Enrollment Process
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 CDKY1If 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 dentalenrollment@Change Healthcare.com
Delta Dental Massachusetts 04614 Visit https://www.deltadentalma/trading-partner/ and complete a new enrollment form denoting reason for submission cancel.
Delta Dental of Maryland and Pennsylvania 23166 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Delta Dental of Michigan CDMI0If 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 dentalenrollment@Change Healthcare.com
Delta Dental of Minnesota CDMN1
Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request.
Phone: 800-328-1188Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
41
Payer ID ERA Un-Enrollment Process
Delta Dental of North Carolina 56101If 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 dentalenrollment@Change Healthcare.com
Delta Dental of North Dakota CDND1
Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request.
Phone: 800-328-1188Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
Delta Dental of Nebraska CDNE1
Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request.
Phone: 800-328-1188Fax: 877-283-1330
Mail: PO Box 9304, Minneapolis, MN 55440-9304
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 85022If 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 dentalenrollment@Change Healthcare.com
Delta Dental of New York 11198 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
42
Payer ID ERA Un-Enrollment Process
Delta Dental of Ohio CDOH1If 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 dentalenrollment@Change Healthcare.com
Delta Dental of Oklahoma CDOK1 None required as provider will continue to receiver paper remits.
Delta Dental of Maryland and Pennsylvania 23166
Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by writtennotification 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 re-
apply 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 95853-7010Or
fax to: (916) 852-8995
Delta Dental Puerto Rico 66043 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
Delta Dental of Tennessee CDTN1If 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 dentalenrollment@Change Healthcare.com
Delta Dental of Washington 91062 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
43
Payer ID ERA Un-Enrollment Process
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 Email request to dentalenrollment@Change Healthcare.com. Include provider name and Tax ID.
DentaQuest - Government Plans CX014 Visit https://www.dentaquest.com/era-enrollment/ and complete a new enrollment form denoting reason for submission cancel.
Medicaid of Alaska CKAK1A 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.
Medicaid of Arkansas CKAR1 If a provider wishes to discontinue receiving ERAs from Arkansas Medicaid call 800-457-4454 or 501-376-221.
44
Payer ID ERA Un-Enrollment Process
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 CKCT1If 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 CKDE1If 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
Florida Medicaid CKFL1If 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 Florida CKFL1If 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.
45
Payer ID ERA Un-Enrollment Process
Medicaid of Georgia CKGA1
Delta Dental of Iowa Medicaid Program CDIAM
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
orEmail [email protected]
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 Children's Special Healthcare CX070If a provider wishes to discontinue receiving ERAs from Change Healthcare the provider needs to re-enroll for ERA retrieval through the Indiana Medicaid web portal selecting
another entity to retrieve their ERAs from Indiana Medicaid.
Medicaid of Indiana CKIN1If a provider wishes to discontinue receiving ERAs from Change Healthcare the provider needs to re-enroll for ERA retrieval through the Indiana Medicaid web portal selecting
another entity to retrieve their ERAs from Indiana Medicaid.
46
Payer ID ERA Un-Enrollment Process
Medicaid of Kansas CKKS1
If a provider wishes to discontinue receiving ERAs from Change Healthcare 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#.
Aetna Better Health of Kentucky 128KY Contact Aetna Better Health of Kentucky
Medicaid of Kentucky CKKY1 If a provider wishes to discontinue receiving ERAs from Kentucky Medicaid call 800-205-4696.
Aetna Better Health Plan of Lousiana 128LA Contact Aetna Better Health of Louisiana
Health Safety Net CKHSN Visit https://www.dentaquest.com/era-enrollment/ and complete a new enrollment form denoting reason for submission cancel.
Massachusetts Health Program CKMA1 Visit https://www.dentaquest.com/era-enrollment/ and complete a new enrollment form denoting reason for submission cancel.
47
Payer ID ERA Un-Enrollment Process
Medicaid of Maine CKME1 Providers must log into their Maine MIHMS account and remove Change Healthcare as the receiver of their 835 transactions
Aetna Better Health of Michigan 128MI Contact Aetna Better Health Plan of Michigan
Medicaid of Michigan CKMI1 Providers deciding to no longer have their ERAs delivered to Change Healthcare need to go into the CHAMPS system and place an end date for Change Healthcare 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 Change Healthcare as their ERA
clearinghouse by completing another Electronic Remittance Advice (RA) Request Form designating another receiver.
HealthPartners MN CX010 Email request to [email protected]. Include provider name and Tax ID.
Aetna Better Health Plan of Missouri 128MO Contact Aetna Better Health of Missouri
48
Payer ID ERA Un-Enrollment Process
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 Change Healthcare 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.
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.
49
Payer ID ERA Un-Enrollment Process
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 CKNJ1If 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/FH-37_service_center_authorization_form.pdf
Aetna Better Health of New York 34734 Contact Aetna Better Health of New York
50
Payer ID ERA Un-Enrollment Process
Medicaid of New York CKNY1If 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) CKNY2If 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 dentalenrollment@Change Healthcare.com. 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 CKOK1If 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.
51
Payer ID ERA Un-Enrollment Process
Medicaid of Oregon CKOR1If 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.
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.
Triple-S Medicaid Advantage PRADV Contact payer at 888-620-1919
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 Change Healthcare'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
52
Payer ID ERA Un-Enrollment Process
Aetna Better Health of Virginia 128VA Contact Aetna Better Health of Virginia
Medicaid of Vermont CKVT1 If a provider wishes to discontinue receiving ERAs from Vermont Medicaid call 802-879-4450 or email [email protected]
Medicaid of Washington CKWA1 Providers who wish to discontinue receiving ERAs need to call Washington DHS at 800-562-3022 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.
Aetna Better Health of West Virginia 128WV Contact Aetna Better Health of West Virginia
Medicaid of West Virginia CKWV1 Please log into your WV Medicaid provider portal account and remove CPSI EDI dba Change Healthcare Dental as the receiver of your ERAs.
53
Payer ID ERA Un-Enrollment Process
Medicaid of Wyoming CKWY1If 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 307-772-8405. The request should be on office letterhead and include Tax ID, NPI, name and mailing address.
