Payer EDI Enrollment Forms
Some payers require pre-enrollment before permitting the provider to submit electronic claims to them. Typically payers such as Medicare, Medicaid, Blue Cross, and Blue Shield require pre-enrollment. Payers that require pre-enrollment are indicated on our Payer Lists (ENR column). As a service to our customers, Office Ally provides these agreements and forms below, pre-filled with Office Ally’s information where ever required. Below is a list of all Pre-Enrollment forms available (sorted by state).
Be sure to complete the form(s) as indicated on the Instructions Cover Page to ensure applications are not denied.
Payer Enrollment Forms (by State):
Click here to view Electronic Remittance (ERA/835) Enrollment Forms
All or Multiple States
DMERC Region A
DMERC Region B
DMERC Region C
DMERC Region D
Garretson Resolution Group
Indian Health Services / VA
(Part A)
Indian Health Services / VA
(Part B)
Intercommunity Health Net
Medicare HHH (J11)
Medicare HHH (J15)
Medicare J04911
Medicare J12901 WPS Legacy (Part A)
Medicare J5 National Part A
Railroad Medicare
TakeCare Insurance Company
TriCare East
TriCare for Life
TriCare Overseas
WPS Arise Health Plan
Arizona
California
Alameda Alliance for Health
Central California Alliance for Health (CCAH)
Contra Costa Health Plan
Denti-Cal (Medi-Cal Dental)
Gold Coast Health Plan
Health Source MSO
Medi-Cal
Medicare California - North
(Part A)
Medicare California - North
(Part B)
Medicare California - South
(Part A)
Medicare California - South
(Part B)
Partnership HealthPlan of California
Valley Health Plan
(Commercial & Medi-Cal)
Colorado
Connecticut
Delaware
Hawaii
Idaho
Indianna
Kansas
Maine
Maryland
Massachusetts
Michigan
Mississippi
Missouri
Montana
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Pennsylvania
Amerihealth / Independence Administrators
BCBS Pennsylvania (Highmark)
BCBS Pennsylvania (UB) (Highmark)
Capital Blue Cross / Keystone Health Plan Central
Highmark Senior Health Company
IBC Personal Choice
Independence Blue Cross
Keystone Health Plan (East)
Medicare Pennsylvania (Part A)
Medicare Pennsylvania (Part B)
Rhode Island
South Carolina
South Dakota
Utah
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
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