PLEASE NOTE how the forms
are handled. Some forms MUST be MAILED back to Signature Claims and
others can be sent or faxed directly to the insurance company
||Enrollment forms for Tri-Care NORTH. This form they
want MAILED directly to Tri-Care North.
||Enrollment forms for Tri-Care SOUTH. This form they
want MAILED directly to Tri-Care South.
| Tri-Care West
||Enrollment forms for Tri-care West. These forms can be
faxed directed to the Tri-Care administration (WPS).
| Tri-Care ERA
|| Send to WPS to receive ERAs
RailRoad Medicare Enrollment
|Enrollment forms for Railroad Medicare. You MUST be a
Railroad Medicare provider.
| EMDEON Enrollment form
|| Use this form when using EMDEON for any insurance
agencies that issue their own provider numbers.
| EMDEON ERA Form
|| Fill this out and fax or email to Emdeon to receive
remittance advice from the commercial payers
||Special Emdon form for Value Options
Jurisdiction States Chart
||For all the
below, use the Signature Claims submitter number of V08900526 and use
your browser and go to
Delaware, District of Columbia, Maine, Maryland, Massachusetts, New
Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin
Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New
Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina,
Tennessee, Texas, Virgin Islands, Virginia, West Virginia
Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri,
Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah,
Washington, Wyoming, Mariana Islands, American Samoa
| Medi-Cal California
||This form is for Medi-Cal
California. You MUST send this back to Signature Claims AND MUST BE
SIGNED IN BLUE INK.
||Enrollment forms for
Medicare-Southern California. This requires a signature from the
||Enrollment forms for
Medicare-Northern California. This requires a signature from the
| Illinois Medicare
|| Need to fill out two forms from NGS.
Include the Signature Claims submitter number of 11753
| Blue Cross/Blue
|| Enrollment form for Availity-Blue Cross/Blue Shield. This
form can be faxed directly to Availity.
| Michigan Blue Cross/Blue
|| Providers must complete a
Provider Trading Partner Agreement online (http://www.bcbsm.com/ ) and enter
their provider codes (and NPI) in Provider Authorization Table
with c0iib as the submitter and receiver. The provider must call
800.542.0945, option 1 to get their login id and password.
| Michigan Medicare
|| These can be faxed back to WPS
information to Signature Claims and Signature Claims will notify
||These can be faxed back
|South Carolina Medicaid
||Mail this form directly
to South Carolina Medicaid AND email your Medicaid information to
Signature Claims because of a separate form that must come from the
Medicare Enrollment Form
|| You need to fill out the following form, sign and fax to
CAHABA. You will also need the Signature Claims submitter number of