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 a
re not denied for incorrect/missing information.



All or Multiple States Payer Enrollment Forms Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas

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Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota

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Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington DC West Virginia Wisconsin Wyoming

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Advanced Tips
Type Example Notes
Fuzzy kettle~ Contain terms that are close to the word kettle, such as cattle
Wild cat* Contain terms that begin with cat, such as category and the extact term cat itself
Exact-Single orange Contain the term orange
Exact-Phrase "dnn is awesome" Contain the exact phase dnn is awesome
OR orange bike Contain the term orange or bike, or both. OR, if used, must be in uppercase
orange OR bike
AND orange AND bike Contain both orange and bike. AND must be in uppercase
Combo (agile OR extreme) AND methodology Contain methodology and must also contain agile and/or extreme
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