Emdeon Dental Payer List
220 Burnham Street ● South Windsor, CT 06074 Vox 888-255-7293 ● Fax 860-289-0055 HOW TO UN-ENROLL DENTAL ELECTRONIC REMITTANCE ADVICE (ERA) DISCONTINUING ERA Discontinuing ERA is a 2 step process. 1. Deactivation a. Providers receiving ERAs via their Practice Management Software need to request deactivation from their software Vendors. Please call your PMS directly. b. Providers receiving their ERAs via an Emdeon DPS account need only ignore the ERA option when logging into the DPS. 2. Payer Un-enrollment a. Each payer has their own unique process to discontinue ERAs and return to paper Remittance Advice. Please identify which payers you wish to un-enroll from and follow the instructions for unenrollment in the far right column next to each of your payers. CONTACT PHONE NUMBER Emdeon Dental Provider Enrollment 888-255-7293 Page 1 of 1 11-15-13: dlv Emdeon Dental Payer List 1/19/2015 Payer AARP ID AARP1 ERA Un-Enrollment Process Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 Advantica Benefits 43168 Email request to dentalenrollment@emdeon.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. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. AGC International Union of Operating Engineers Local 701 AK United Food and Commercial Workers (AK UFCW) Alask Carpenters Alaska Hotel Employees, Restaurant & Camp Employees (AK HERE) 1 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.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 Alaska Laborers Construction Industry Health & Security Trust Alaska Machinists Health and Welfare Trust Alaska Pipe Trades U A Local 375 Alaska Public Employees Association (APEA/JESS Health & WelfareTrust) Allied Metal Crafts Security Plan Trust Fund 2 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Association Benefit Plan 25133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Assurant Health (IM & GROUP FULLY - INSURED ) 39065 If a provider wishes to discontinue receiving ERAs from Assurant Health / Time Insurance Co. email request to ediserve@assurant.com making sure to include his Tax ID, name and mailing address. Benefit Inc. R7003 Benefit Systems & Services, Inc. (BSSI) 36342 Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request. Phone: 800-328-1188 Fax: 877-283-1330 Mail: PO Box 9304, Minneapolis, MN 55440-9304 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Please visit one of the below sites to request to discontinue ERA services. Blue Care Family Plan California State Government Programs GWD01 CPPCA All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 CareFirst, Inc. Maryland BCBS 00580 3 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Central Reserve Life 34097 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. CHAMPVA - HAC 84147 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. CIGNA 62308 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Community Health Electronic Claims/CHEC/webTPA 75261 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Connecticut General (CIGNA) 62308 Email request to dentalenrollment@emdeon.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. Cement Masons and Plasterers Health & Welfare Trust 4 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process CoreSource Little Rock 75136 If a provider wishes to discontinue receiving ERAs from CoreSource Little Rock email the request to payorid75136@coresource.com CoreSource MD PA IL 35182 If a provider wishes to discontinue receiving ERAs from CoreSource MD PA IL email request to payorid35182@coresource.com CoreSource NC IN 35180 If a provider wishes to discontinue receiving ERAs from CoreSource NC IN email request to payorid35180@coresource.com Coventry Health Care 25133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Coventry Health Care Carelink 25133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Coventry Health Care Carelink Medicaid 25133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Coventry Health Care National Network 25133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 5 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Coventry Missouri 25133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. CTI Administrators 42141 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Dart Management Corp. 06172 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Contact DeCare Networks Professional Services department either via phone or in writing stating your request. Phone: 800-658-4187 Fax: 800-658-4186 Mail: PO Box 1175, Minneapolis, MN 55440-1175 DeCare Dental Health Insurance 07035 Dental Benefit Providers 52133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Dental Select CX093 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Deseret Mutual Benefit Administrators CX089 Contact DMBA EDI Enrollment via email to EDIenrollment@dmba.com or via phone at 800-777-3622. 6 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process EMI Health CX079 If a provider wishes to discontinue receiving ERAs from EMI Health call 800-662-5851 and make his request. Employers Mutual, Inc. 59297 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. EQUICOR 62308 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. ExclusiCare 71412 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Fairbanks North Star Borough Fairbanks North Star Borough School District Plan A (FNSBSD) Fairbanks North Star Borough School District Plan B (FNSBSD) 7 Emdeon Dental Payer List 1/19/2015 Payer First Reliance Standard Life Ins. Co. (NY Business) ID 13317 Flex Compensation R7004 Foreign Service Benefit Plan 25133 ERA Un-Enrollment Process No un-enrollment is required by the payer. Paper EOPs can be obtained at http://www.ameritas.com/index.htm Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request. Phone: 800-328-1188 Fax: 877-283-1330 Mail: PO Box 9304, Minneapolis, MN 55440-9304 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Please visit one of the below sites to request to discontinue ERA services. GIC Indemnity Plan 80314 Gilsbar, Inc. 07205 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Please visit one of the below sites to request to discontinue ERA services. Golden West Dental Government Employees Hospital Association (GEHA) GWD01 44054 8 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ If a provider wishes to discontinue receiving ERAs from GEHA email request to daryl.evans@geha.com. Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Great-West Healthcare 80705 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Group Benefit Administrators 72153 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Guardian Life Insurance Company of America 64246 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Hawaii - Mainland Administrators 86066 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Hawaii Medical Service Association (HMSA) HMSA1 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Hawaii Western Management Association (HMAA/HWMG) 99208 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Health Choice Arizona 62179 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 9 Emdeon Dental Payer List 1/19/2015 Payer Healthgram, Inc. ID 56144 ERA Un-Enrollment Process Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Providers based in MN who no longer wish to receive their HealthPartner ERAs from Emdeon must enroll online at https://www.healthpartners.com/providerregistration/entry.do to receive their remittance advices online. HealthPartners MN CX009 Providers based outside MN who no longer wish to receive their HealthPartner ERAs from Emdeon should email request to dentalenrollment@emdeon.com. 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@emdeon.com. Include provider name and Tax ID. HealthSmart Benefit Solutions 37272 Email request to dentalenrollment@emdeon.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 susie_black@healthsmart.com 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Hotel Employees Restaurant Employees Health Trust (HERE) 10 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Humana, Inc. 61101 • Email request to dentalenrollment@emdeon.com. • Include provider name and Tax ID. Insurance Program Managers Group (IPMG) 36342 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. John Alden Life Insurance Co. 41099 If a provider wishes to discontinue receiving ERAs from John Alden Life Insurance Co. email request to ediserve@assurant.com making sure to include Tax ID, name and mailing address. Jopari Careworks J1410 Log on to Jopari Portal at www.jopari.com using your unique User ID and Password to access the ERA Enrollment menu. A menu will allow you to select 'Reason for Submission' to enable you to discontinue ERAs and return to paper Remittance Advice. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Mail Handlers Benefit Plan 25133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Mayo Clinic Health Solutions 41154 Provider must call MMSI Customer Service at 800-533-1564 and make a request. Locals 302 & 612 of the Internation Union of Operating Engineers 11 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process MBS 56205 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. MED3000 CMS Early Steps EM350 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Med3000 CMS Title 19 Reform EM843 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Med3000 CMS Title 21 EM205 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. MED3000 Pedicare Title 21 EM522 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. MedCost Benefit Services 56205 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. MEDICA of Minnesota CX026 12 Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request. Phone: 800-328-1188 Fax: 877-283-1330 Mail: PO Box 9304, Minneapolis, MN 55440-9304 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Medical Benefits Mutual Administrators (MedBen) 74323 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Medical Mutual of Ohio 29076 If a provider wishes to discontinue receiving ERAs from Medical Mutual of Ohio call Provider Contracts at 800-625-2583. Medical Mutual of Ohio CB833 If a provider wishes to discontinue receiving ERAs from Medical Mutual of Ohio call Provider Contracts at 800-625-2583. Medico Insurance Company 23160 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Mercy Care Plan 86052 If a provider wishes to discontinue receiving ERAs from Mercy Care Plan call 602-2633000 or 800-624-3879 Express Service Code 631. Mercy Maricopa Integrated Care 33628 Please contact Mercy Maricopa Integrated Care for assistance. 602-586-1880 or 866602-1979 MetLife 65978 Please visit https://www.metdental.com/prov/execute/home for instructions. 13 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Municipal Health Benefit Fund 81883 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Mutual of Omaha Commercial CX087 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Mutual of Omaha Insurance Company 71412 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Mutually Preferred 71412 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. National Rural Letter Carrier Association 71412 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. New England Dental Administrators 43351 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Nippon Life Insurance Company of America 81264 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 14 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. J1410 No un-enrollment is available. Jopari CareWorks requires claims submitted EDI (837D) to have remits delivered EDI (835). Northwest Ironworkers Health & Security Fund Northwest Roofers & Employers Health & Security Trust Fund Northwest Textile Processors and Service Trades NW International Association of Machinists (NW IAM) NW Plumbers & Pipefitters Health & Welfare Trust Ohio Dept of Corrections (Careworks) OK State Employees & Educators (EDS) 22521 15 Providers should submit a new agreement with the Reason for Submission denoted as Cancel Enrollment to the below. In Network providers fax to 405-717-8977 Non Network providers email to hpera.mailbox@hp.com. Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process PacificSource Health Plans 93029 Providers who wish to discontinue receiving ERAs need to call PacificSource Health Plans and make the request. 800-624-6052 PEHP (Public Employees Health Program) CX080 Please call or email the PEHP helpdesk at 801-366-7544, 800-753-7818 or edi.helpdesk@pehp.org to request discontinuance of ERAs. Physicians Mutual CX068 No un-enrollment is required by the payer. Paper EOPs can be obtained at http://www.ameritas.com/index.htm Pittman & Associates 37224 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. POMCO 16111 If a provider wishes to discontinue receiving ERAs from POMCO call 315-432-9171 ext. 4255. Preferred Care Partners 65088 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Preferred One 41147 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 16 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process PrimeWest Health LX049 Paper remits are not available effective 1-1-13. Providers can access the Prime West Health Portal to obtain explanation of payment (EOP). Please contact the Call Center for assistance at 866-431-0802. Principal Financial Group 61271 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Priority Health 38217 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 91136 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 36088 No un-enrollment is required by the payer. Paper EOPs can be obtained at http://www.ameritas.com/index.htm Puget Sound Electrical Workers Healthcare Trust (PSEW) Reliance Standard Life Please visit one of the below sites to request to discontinue ERA services. Reliastar 80314 Renaissance Life and Health RLHA1 17 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Emdeon Dental Payer List 1/19/2015 Payer Reserve National Insurance Company ID 73066 ERA Un-Enrollment Process Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Please visit one of the below sites to request to discontinue ERA services. All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Rocky Mountain Life Dental 84102 Rural Carrier Benefit Plan 25133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. SafeGuard PPO CX030 Please visit https://www.metdental.com/prov/execute/home for instructions. Contact DeCare Networks Professional Services department either via phone or in writing stating your request. Phone: 800-658-4187 Fax: 800-658-4186 Mail: PO Box 1175, Minneapolis, MN 55440-1175 Securian 93742 Select Health CX107 Please call 801-442-5442 and request to be returned to paper remits. Sheffield, Olson and McQueen 41143 Provider would need to mark Cancel and complete section A of the Electronic Remittance Advice & Electronic fund Transfer Request Form and fax to 651-389-9152. 18 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Standard Ins. Co. (OR Business) 93024 No un-enrollment is required by the payer. Paper EOPs can be obtained at http://www.ameritas.com/index.htm Standard Insurance Company (NY) 13411 No un-enrollment is required by the payer. Paper EOPs can be obtained at http://www.ameritas.com/index.htm Sun Life and Health Insurance Company 67814 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. Surency Life and Health CX088 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. Time Insurance Company 39065 If a provider wishes to discontinue receiving ERAs from Assurant Health / Time Insurance Co. email request to ediserve@assurant.com making sure to include his Tax ID, name and mailing address. Total Broker Benefits 36342 Email request to dentalenrollment@emdeon.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. 19 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process TransChoice - Key Benefit Administrators 37284 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. UMR - Wausau/UHIS 39026 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Please visit one of the below sites to request to discontinue ERA services. All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ UNICARE 80314 United Concordia - Dental Plus CX013 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. United Concordia - Fee for Service CX007 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. United Concordia - Tricare Dental Plan CX002 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. United of Omaha 71412 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 20 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process University of Missouri 25133 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. UPMC Health Plan 23281 Email request to dentalenrollment@emdeon.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 Emdeon at 860-289-0055. 91136 Email request to dentalenrollment@emdeon.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 susie_black@healthsmart.com Wells Fargo TPA, Inc (Charleston, WV) 87815 If a provider wishes to discontinue receiving ERAs from Wells Fargo Third Party Administrators email request to susie_black@healthsmart.com Wells Fargo TPA, Inc. (Newnan, GA and Fayetteville, NC) 37272 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Washington State Council of County & City Employees (WSCCCE) 21 Emdeon Dental Payer List 1/19/2015 Payer WilsonMcShane ID R7002 ERA Un-Enrollment Process Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request. Phone: 800-328-1188 Fax: 877-283-1330 Mail: PO Box 9304, Minneapolis, MN 55440-9304 36123 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Horizon Healthcare Dental Services 22099 If a provider wishes to discontinue receiving ERAs from Horizon Healthcare Dental Services fax a letter of request to the payer at 973-274-4154 attention Shirley Antoine. The letter must be typed on office letterhead and contain Tax ID and Provider name. NorthStar Administrators 47570 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. Premera Blue Cross 47570 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. Blue Cross of Alaska and Washington 47570 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. Blue Cross of Alabama CBAL1 If a provider wishes to discontinue receiving ERAs from Blue Cross of Alabama fax request to 205-220-9266 on office letterhead. Dearborn National 22 Emdeon Dental Payer List 1/19/2015 Payer Blue Cross of Arkansas ID CBAR1 ERA Un-Enrollment Process Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Please visit one of the below sites to request to discontinue ERA services. Anthem Blue Cross CA 47198 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Please visit one of the below sites to request to discontinue ERA services. Blue Cross of Colorado 84099 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Please visit one of the below sites to request to discontinue ERA services. Trigon Blue Cross Blue Shield - Colorado Dental Office 84103 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Please visit one of the below sites to request to discontinue ERA services. Anthem Blue Cross Blue Shield Connecticut 84105 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Please visit one of the below sites to request to discontinue ERA services. Blue Care Family Plan (BCBS of CT) 00700 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Please visit one of the below sites to request to discontinue ERA services. Blue Cross of Georgia CBGA1 23 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Blue Cross of Iowa CBIA2 If a provider wishes to discontinue receiving ERAs from Blue Cross of Iowa complete the Electronic Transaction Registration Form leaving the 835 box blank. The form is available at http://wellmark.com/e_business/provider/forms/frmsprovider.htm. Blue Shield of Idaho CBID2 No un-enrollment is necessary at Providers will continue to be able to see their remits in the Regence Provider Center websites. Blue Cross of Illinois CB621 Email request to dentalenrollment@emdeon.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. Please visit one of the below sites to request to discontinue ERA services. All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Blue Cross of Kentucky Anthem 84105 Blue Cross Blue Shield of Louisiana 23739 Submit a new Electronic Remittance Advice (ERA) Enrollment Form directly to LA BCBS denoting the Reason for Submission as Cancel Enrollment. Blue Cross of Massachusetts CBMA1 Send request to dentalenrollment@emdeon.com. Include the provider's name, Tax ID and NPI. 24 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Blue Cross Blue Shield of Michigan CBMI1 Email request to dentalenrollment@emdeon.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 edisupport@bcbsm.com. 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 Deborah.Young@bluekc.com requesting ERAs be discontinued. Blue Cross of Mississippi CBMS1 If a provider wishes to discontinue receiving ERAs from BCBS of Mississippi call 800-8264068. Blue Cross Blue Shield of Montana CBMT1 Contact your Montana BCBS representative. Blue Cross of North Dakota (ND Dental Services) CX004 If a provider wishes to stop receiving ERAs, a Termination Form is required to be submitted to ND BCBS. Please call EDI Support Services for the form and instructions. Blue Cross of Nebraska CBNE1 If a provider wishes to discontinue receiving ERAs from BC of Nebraska call Sean Blair at 402-392-4205. Blue Cross of New Mexico SB790 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. 25 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Please visit one of the below sites to request to discontinue ERA services. Blue Cross of Nevada Empire Blue Cross Blue Shield 84101 CBNY1 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Contact DeCare Networks Professional Services department either via phone or in writing stating your request. Phone: 800-658-4187 Fax: 800-658-4186 Mail: PO Box 1175, Minneapolis, MN 55440-1175 Please visit one of the below sites to request to discontinue ERA services. All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Blue Cross of Ohio Anthem 84105 Blue Cross blue Shield of Oklahoma SB840 Email request to dentalenrollment@emdeon.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@emdeon.com. Include provider name and Tax ID. CBPA2 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Pennsylvania Blue Shield Dental Plus 26 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process CB870 If a provider wishes to discontinue receiving ERAs from BC of Rhode Island mail a letter of request on letterhead which contains the provider's full name, Tax ID and/or Provider ID, Submitter ID and reason for discontinuance to: Attn: Contracting Department Blue Cross of Rhode Island, 15 LaSalle Square, Providence, RI 02903. South Carolina BCBS 38520 Effective 1-1-10: Paper RAs are no longer available from South Carolina BCBS. Should a provider wish to discontinue receiving ERAs from Emdeon the provider needs to re-enroll for ERA retrieval through SC BCBS or re-enroll electing another entity to retrieve their ERAs from SC BCBS. Provider may contact BlueCross Provider Education at 803-2644730 for additional information. Blue Cross of Texas CB900 Email request to dentalenrollment@emdeon.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. Blue Cross of Rhode Island Please visit one of the below sites to request to discontinue ERA services. Trigon Blue Cross of Virginia (Anthem BCBS-VA/ BCBS Anthem-VA formerly Trigon) CB923 Blue Cross of Alaska and Washington 47570 27 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. Emdeon Dental Payer List 1/19/2015 Payer Regence Blue Shield ID 93200 ERA Un-Enrollment Process No un-enrollment is necessary at Providers will continue to be able to see their remits in the Regence Provider Center websites Please visit one of the below sites to request to discontinue ERA services. Blue Cross of Wisconsin Delta Dental Insurance Co. (DDIC) - All Payers CB950 94276 All states - https://www.anthem.com/dentalproviders/ GA - http://www.bcbsga.com/home-providers.html NY - http://www.empireblue.com/home-providers.html CA - https://www.anthem.com/dentalproviders/ Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 Northeast Delta Dental (ME, NH, VT) 02027 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Delta Dental of Arizona 86027 If a provider wishes to discontinue receiving ERAs from Delta Dental of Arizona send a written request to the below address. Please include the provider’s name, Tax ID, and statement of request. Delta Dental of Arizona PO Box 43000 Phoenix, AZ 85080-3000 Delta Dental of California - CA00 Claims Office 77777 Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 Delta Dental of Washington DC 52147 28 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Emdeon Dental Payer List 1/19/2015 Payer Delta Dental of Delaware ID 51022 ERA Un-Enrollment Process Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 Delta Dental of Iowa CDIA1 If a provider wishes to discontinue receiving ERAs from Delta Dental Iowa a new enrollment form with the reason for submission denoted as Cancel needs to be submitted to Delta Dental of Iowa. Fax 515-261-5608 or Email provrelations@deltadentalia.com Delta Dental of Idaho 82029 Any provider with questions about enrollment in the ERA program should just call our customer service department at: 208-489-3580 or 800-356-7586 or email to customerservice@deltadentalid.com. Delta Dental of Illinois Group Plans 05030 Providers are required to give Delta Dental of Illinois written notification. Mail notifications to: Professional Relations Department Delta Dental of Illinois 801 Ogden Avenue Lisle, IL 60532 Delta Dental of Indiana CDIN1 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Delta Dental of Kansas CDKS1 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. Delta Dental of Kentucky CDKY1 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com 29 Emdeon Dental Payer List 1/19/2015 Payer Delta Dental of Maryland and Pennsylvania ID 23166 ERA Un-Enrollment Process Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 Delta Dental of Michigan Blue Cross and Blue Shield of Minnesota CDMI0 CDMN1 Delta Dental of Minnesota CDMN1 Delta Dental of North Carolina 56101 Delta Dental of North Dakota Delta Dental of Nebraska CDND1 CDNE1 30 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request. Phone: 800-328-1188 Fax: 877-283-1330 Mail: PO Box 9304, Minneapolis, MN 55440-9304 Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request. Phone: 800-328-1188 Fax: 877-283-1330 Mail: PO Box 9304, Minneapolis, MN 55440-9304 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request. Phone: 800-328-1188 Fax: 877-283-1330 Mail: PO Box 9304, Minneapolis, MN 55440-9304 Contact Delta Dental of Minnesota Professional Services department either via phone or in writing stating your request. Phone: 800-328-1188 Fax: 877-283-1330 Mail: PO Box 9304, Minneapolis, MN 55440-9304 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Delta Dental of New Jersey 22189 Please contact DDNJ at 800-452-9310 and request to return to paper remits. Delta Dental of New Mexico 85022 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Delta Dental of New York 11198 Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 Delta Dental of Ohio CDOH1 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Delta Dental of Oklahoma CDOK1 None required as provider will continue to receiver paper remits. Delta Dental of Maryland and Pennsylvania Delta Dental Puerto Rico 23166 66043 Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 31 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Delta Dental of Tennessee CDTN1 If a provider wishes to discontinue receiving ERAs from Dart Container Corp., Delta Dental of NC, IN, KY, MI, NM, OH, TN, Group Benefits Admin of TN, and Renaissance Life & Health email request to dentalenrollment@emdeon.com Delta Dental of Virginia CDVA1 Complete a new form following the directions for cancellation. Submit the form to: Delta Dental of Virginia 4818 Starkey Road, Roanoke, VA 24018 Delta Dental of Washington 91062 Email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Delta Dental of Wisconsin 39069 If a provider wishes to discontinue receiving ERAs from Delta Dental Wisconsin email request to pr@deltadentalwi.com or call Provider Relations at 800-836-0490. Delta Dental of West Virginia 31096 Providers may elect to discontinue Delta Dental’s ERA (revert to paper EOB) by written notification to Delta’s Dental Network Administration and Contracting department. Allow ninety (90) days for business data validation, setup, testing and production implementation. Provider IDs removed from the ERA process will not be allowed to reapply for ERA processing for a period of one (1) calendar year. Please mail your request to: Delta Dental of California Dentist Network Administration and Contracting (DNAC) P.O. Box 537010 Sacramento, CA 95853-7010 Or fax to: (916) 852-8995 Medicaid of Alaska CKAK1 A faxed letter of request must be sent on letterhead to 907-644-8126 to request disenrollment. Please note the letter needs to be signed by the contact person listed in Alaska Medicaid’s system. Medicaid of Alabama CKAL1 If a provider wishes to discontinue receiving ERAs from Alabama Medicaid contact Provider Enrollment at 800-456-1242 or 334-215-0111. 32 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Medicaid of Arkansas CKAR1 If a provider wishes to discontinue receiving ERAs from Arkansas Medicaid call 800-4574454 or 501-376-221. Denti-Cal / Medicaid of California 94146 If a provider wishes to discontinue receiving ERAs from Denti-Cal / Medicaid of California call 916-853-7373 and make the request. Medicaid of Connecticut CKCT1 If a provider wishes to discontinue receiving ERAs from Medicaid of Connecticut he needs to fax a letter of request to 860-269-2027. The letter must include the statement, “I no longer want to receive 835s”, the provider’s name, Tax ID and address. District of Columbia Medicaid CKDC1 If a provider wishes to discontinue receiving ERAs from Washington, D.C. Medicaid mail a letter of request on letterhead which contains the provider's full name, Tax ID and Provider ID with the reason for discontinuance to: ACS Provider Enrollment Unit, PO Box 4761, Washington, DC 20043-4761. Delaware Medicaid CKDE1 If a provider wishes to discontinue ERAs with Delaware Medicaid a written letter of request must be completed on the office’s letterhead with an authorized signature and mailed to: Delaware Medicaid, Provider Relations, PO Box 909, Manor Branch, New Castle, DE 19720 Medicaid of Florida CKFL1 If a provider wishes to discontinue receiving ERAs from Florida Medicaid mail a letter or request on letterhead with provider signature to: ACS State Healthcare - Provider Enrollment, 2308 Killearn Ctr. Blvd., Ste. 100, Tallahassee, FL 32309. Medicaid of Georgia CKGA1 If a provider wishes to discontinue receiving ERAs from Georgia Medicaid mail a Remit Option Form to ACS, PO Box 4000, McRae, GA 31055. The form can be found at www.ghp.georgia.gov. 33 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Medicaid of Iowa CKIA1 Effective 3-1-10, un-enrollment will no longer be allowed as paper remits will cease. Providers may only change where they retrieve ERAs from. Aetna Better Health of Illinois 26337 Contact Aetna Better Health of Illinois Indiana Childrens Special Healthcare CX070 If a provider wishes to discontinue receiving ERAs from Emdeon the provider needs to reenroll for ERA retrieval through the Indiana Medicaid web portal selecting another entity to retrieve their ERAs from Indiana Medicaid. Medicaid of Indiana CKIN1 If a provider wishes to discontinue receiving ERAs from Emdeon the provider needs to reenroll for ERA retrieval through the Indiana Medicaid web portal selecting another entity to retrieve their ERAs from Indiana Medicaid. Medicaid of Kansas CKKS1 If a provider wishes to discontinue receiving ERAs from Emdeon login to the KMAP account and remove WEBMDDENTAL as the receiver of 835s. 835s will than begin being delivered to the provider’s KMAP account. Should a provider wish to return to paper RAs call the KMAP Customer Service line at 800-933-6593 option 1, option 3#. Medicaid of Kentucky CKKY1 If a provider wishes to discontinue receiving ERAs from Kentucky Medicaid call 800-2054696. Medicaid of Maine CKME1 Providers must log into their Maine MIHMS account and remove Emdeon as the receiver of their 835 transactions 34 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Medicaid of Michigan CKMI1 Providers deciding to no longer have their ERAs delivered to Emdeon need to go into the CHAMPS system and place an end date for Emdeon as the receiver. Medicaid of Minnesota CKMN1 Not allowed per Minnesota Statutes 62J.536 which requires electronic only RAs by 12/15/09. Providers may however opt to remove Emdeon as their ERA clearinghouse by completing another Electronic Remittance Advice (RA) Request Form designating another receiver. Providers based in MN who no longer wish to receive their HealthPartner ERAs from Emdeon must enroll online at https://www.healthpartners.com/providerregistration/entry.do to receive their remittance advices online. HealthPartners MN CX010 Providers based outside MN who no longer wish to receive their HealthPartner ERAs from Emdeon should email request to dentalenrollment@emdeon.com. Include provider name and Tax ID. Medicaid of Missouri CKMO1 If a provider wishes to discontinue receiving ERAs from Missouri Medicaid call the Infocrossing Healthcare Services Help Desk at 573-635-3559. Medicaid of Mississippi CKMS1 Paper RAs are no longer available from Mississippi Medicaid. Should a provider wish to discontinue receiving ERAs from Emdeon the provider needs to re-enroll for ERA retrieval through the Mississippi Medicaid web portal or re-enroll electing another entity to retrieve their ERAs from Mississippi Medicaid. Medicaid of Montana CKMT1 If a provider wishes to discontinue receiving ERAs from Montana Medicaid mail request to: DPHHS, PO Box 202951, Helena, MT 59620-2951 Medicaid of North Carolina CKNC1 Effective July 1, 2013 all Provider Enrollment Applications and updates must be completed through the NCTracks system. 35 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Aetna Better Health of Nebraska 42130 Contact Aetna Better Health of Nebraska Medicaid of Nebraska CKNE1 If a provider wishes to discontinue receiving ERAs from Nebraska Medicaid submit a Nebraska Medicaid Trading Partner Authorization form listing an end date. Medicaid of New Hampshire CKNH1 If a provider wishes to discontinue receiving ERAs from New Hampshire Medicaid send a letter of request to: EDS, PO Box 2040, Concord, NH 03302-2040. Aetna Better Health Plan of New Jersey 46320 Contact Aetna Better Health of New Jersey Medicaid of New Jersey CKNJ1 If a provider wishes to discontinue receiving ERAs from New Jersey Medicaid send a letter of request on letterhead with an authorized signature to: NJ Medicaid, PO Box 4804, Trenton, NJ 08650. New Mexico Medicaid CKNM1 Email request to HIPAAHelpdesk@acs-inc.com Medicaid of Nevada CKNV1 If a provider wishes to discontinue ERAs with Nevada Medicaid complete a new FH-37 form completing the terminate a transaction section. Forms are available at: https://nevada.fhsc.com/Downloads/provider/FH37_service_center_authorization_form.pdf 36 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Medicaid of New York CKNY1 If a provider wishes to discontinue receiving ERAs from NY Medicaid complete the Electronic Remittance 835/820 Request form denoting paper as method of remittance retrieval. The form should than be faxed to 518-257-4632. Medicaid of New York (Dental Clinics Only) CKNY2 If a provider wishes to discontinue receiving ERAs from NY Medicaid complete the Electronic Remittance 835/820 Request form denoting paper as method of remittance retrieval. The form should than be faxed to 518-257-4632. NYS DOH UCP 14142 Email request to dentalenrollment@emdeon.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 CKOK1 If a provider wishes to discontinue receiving ERAs from Oklahoma Medicaid submit a new EDI 835 application marking the box titled, Disable the 835 and resume paper RA effective immediately. Medicaid of Oregon CKOR1 If a provider wishes to discontinue receiving ERAs from Oregon Medicaid submit a change form (Exhibit C). Providers should call 503-947-5347 for instructions and a copy of the form. 37 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Medicaid of Pennsylvania CKPA1 If a provider wishes to discontinue ERAs send request to the EDI Department, 225 Grandview Avenue, Mail Stop B100, Camp Hill, PA 17011 or papac@eds.com. The request must include the provider name, Tax ID, Promise number, Group Promise number, contact person, phone number and date they wish to stop receiving ERAs and return to paper. Medicaid of Rhode Island CKRI1 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. Medicaid of Texas CKTX1 If a provider wishes to discontinue receiving ERAs from Texas Medicaid call the EDI Helpdesk at 888-863-3638 option 3. Medicaid of Utah CKUT1 If a provider wishes to discontinue receiving ERAs from Utah Medicaid visit the online enrollment tool for Utah Medicaid and remove Emdeon's Trading Partner number from the line titled 835 Remittance Advice. The web address for the tool is http://hcf.health.utah.gov/hcfenroll/index.jsp Medicaid of Vermont CKVT1 If a provider wishes to discontinue receiving ERAs from Vermont Medicaid call 802-8794450 or email vtedicoordinator@eds.com Medicaid of Washington CKWA1 Providers who wish to discontinue receiving ERAs need to call Washington DHS at 800562-3022 and make the request. Medicaid of Wisconsin CKWI1 No un-enrollment is necessary as the provider will always continue to receive paper remittance advice statements. 38 Emdeon Dental Payer List 1/19/2015 Payer ID ERA Un-Enrollment Process Medicaid of West Virginia CKWV1 Please log into your WV Medicaid provider portal account and remove CPSI EDI dba Emdeon Dental as the receiver of your ERAs. Medicaid of Wyoming CKWY1 If a provider wishes to discontinue receiving ERAs from Wyoming Medicaid mail request to: Attn: EDI Enrollment Unit, PO Box 667, Cheyenne, WY 82003 or fax to 307-7728405. The request should be on office letterhead and include Tax ID, NPI, name and mailing address. 39
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