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Download - Carrier or Payor Enrollment Forms

Note: Enrollment with LTC is required prior to enrollment with Carriers or Payors.

If you need the Adobe Acrobat Reader in order to read the (.PDF) file format, download the free version here first...

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Claim Enrollments

ERA Enrollments

 



Software Installations

    • LTC-SFTP Software Install - Note: When attempting to install in Windows 7 or 8, if you get the pop up message "Windows protected your PC" or "not commonly downloaded...", click the small "More info" text or drop down arrow to the right and then choose "Run anyway" or "Keep". This will save the download file. Then launch to install.

    • LTC-WEB Software Install - Note: When attempting to install in Windows 7 or 8, if you get the pop up message "Windows protected your PC" or "not commonly downloaded...", click the small "More info" text or drop down arrow to the right and then choose "Run anyway" or "Keep". This will save the download file. Then launch to install.
    • Splashtop Remote Access Client Software Install - Installation for Windows pc.

    • Software for Printing ERA 835 Format (EasyPrint)

    • Fileseek Software - Software that allows you to search your local folders for any type of data segment - helpful for sifting through your downloaded reports.



Medical Enrollment Forms

 

(ERA 835) Electronic Remittance Advice Enrollments (Authorization Forms and Instructions)

Medical

  • Aetna (60054) - use this fax number instead of what is listed in the form: 719-785-5290
  • Availity - all Availity carriers
    • BCBS of Illinois (BBIL1)
    • BCBS Texas (BBTX1, 84980)
    • Blue Cross Blue Shield of Minnesota (BBMN1)
    • BLUE CROSS OF OREGON (BBOR1)
    • Blue Plus Exams (Blue Cross Blue Shield of Minnesota) (BPMN1)
    • Blue Plus Supply (Blue Cross Blue Shield of Minnesota) (BPMNS)
    • Blue Shield of Oklahoma (BSOK1)
    • Coordinated Benefits Plan (14829)
    • Directors Guild of America - Producer Health Plan (23706)
    • Florida Medicare (MRFL1)
    • MCare of Colorado Springs (CSMED)
    • Medicaid of Illinois (MDIL1)
    • Physician United Plan (10775)
    • Physicians United Health Plan (TH131)
    • REGENCE BCBS Washington (BBWAR)
    • Today's Health (WITH1)
    • Writers Guild-Industry Health Plan (23710)
  • BCBS of MI - online registration. Note: Unique receiver I.D. and submitter I.D. is C0HDA (second digit is a zero).
  • BCBS of MO
  • BCBS of OH, IN, KY
  • BCBS of WI
  • Cigna (62308) - use this fax number instead of what is listed in the form: 719-785-5290
  • DMERC- all regions (16003, 17003, 18003, 19003) -
    Under the field "ELECTRONIC REMITTANCE ADVICE CLEARINGHOUSE INFORMATION" use the info below:
    Clearinghouse Name: Lindsay Technical Consultants, Inc.
    Clearinghouse Contact Name: Jeff Lindsay
    email: medhelp@lindtech.com
    Under "ELECTRONIC REMITTANCE ADVICE VENDOR INFORMATION" select "OTHER" for the vendor name list at the bottom.
  • Florida Medicare (MRFLA)
  • HealthPartners (HLTHC) - email LTC to set it up.
  • Humana (61101) - instructions for online enrollment.
  • Landmark Healthcare (LNDMK)
  • Medica (MEDIC) - use this fax number instead of what is listed in the form: 719-785-5290
  • MHP(10850) - contact MHP Provider Services at 877-620-9090. Arrange to get the ERA through "Emdeon". Notify us (LTC) once you have completed this.
  • Minnesota Blue Cross Blue Shield (BBMN1, BPMN1, BPMNS) - call or email LTC to set up your provider.
  • Minnesota Medicaid (MNMA1) - providers will be able to download either the 835 or an EOB as Adobe PDF from the MN Medicaid web site. LTC, Inc. can also arrange to send these along with standard LTC reports to the provider. Begin with completion of this application.
  • MMSI (41154) - email LTC to set it up.
  • NGS Medicare - IL, MN and WI (ILMR1, MRMN1, WIMR1)
    Method of Retrieval: "Clearinghouse"
    Clearinghouse Name: Lindsay Technical Consultants, Inc.
    Clearinghouse Contact Name: Jeff Lindsay
    Phone#: 952-942-2774
    E-mail: medhelp@lindtech.com
  • Ohio Blue Cross Blue Shield (BBOH1)
  • Ohio Medicaid (OHMD1) - use data requested below
    Trading Partner/Clearinghouse Name: Lindsay Technical Consultants, Inc.
    7-digit Trading Partner Number: 0006004
    Clearinghouse Contact Name: Jeff Lindsay
    Phone#: 952-942-2774
    E-mail: medhelp@lindtech.com
  • Railroad Medicare (MRRR2)
  • Tricare North (TRICN)
  • Tricare West and Tricare for Life (TRICW, TRICL) - Use 10726 for "Receiver Number"
  • UCare (19991) - select "ClaimLynx" as the clearinghouse.
  • United Healthcare (87726) - use this fax number instead of what is listed in the form: 719-785-5290
  • West Virginia Medicare (WVMR1)
  • WPS Commercial (WPSC1)
  • WPS Commercial - EFT (WPSC1)
  • WPS Medicare - all states (MRIA1, ILMR1, MRIN1, MRKC1, MRKS1, MIMR1, MRMN1, MRMO1, MRNE1, WIMR1)
    -Select Part B J5 for: IA, KC, KS, MO and NE
    -Select Part B J8 for: IN and MI
    -Select Part B JX for: IL, MN and WI

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Gateway Clearinghouse Enrollment Forms (clearinghouses in partnership with LTC)


Enrollment Forms: via ENS

Please note: Do not download or click on any other carrier form other than the one you are seeking.

Enrollment Forms: other

 

Start Here!

New Client Forms for Providers and/or Billing Centers new to LTC

 

 

If you need the Adobe Acrobat Reader in order to read the (.PDF) file format,
download the free version here first...

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