Payer Identification Information Claims Processing Eligibility ...and be sure to submit all required fields, including Payor Name and Complete Address. (C) 2014 Tesia Clearinghouse

Tesia Clearinghouse

www.Tesia.com

1540 W Edgewood Drive

Indianapolis, IN 46217

Tel: (800) 724-7240

Clearinghouse Payer List

eAttachments

Payer ID Payer Name Additional Info Status

Enrollment

Required Type

270s

Available

Enrollment

Required Type

Level of

Response Eligibility Notes

835s

Available

Enrollment

Required

Paper EOBs

Shutoff

when

Enrolled ERA Notes

Accepts Tesia

eAttachments

CX044 A & I Benefit Plan Administrators Non Par Batch39640 A&D Charitable Foundation Inc (dba GreatLakes PACE) a Mediture Payer Non Par BatchAARP1 AARP Dental Insurance Plan Par Batch TRUE RT Detailed TRUE S TRUE TRUE43178 Acceptius (Benefit Management Inc of MO) Non Par BatchTLZ17 Access Administrators (CA ONLY) Par Batch TRUECX097 Access Dental Non Par Batch64071 Acclaims Non Par BatchTLX81 ACEC Health Plans (Salt Lake City, UT) Par Batch TRUE S TRUE Must Enroll in EFT First TRUE72468 ACS Benefit Consulting Services, Inc. Non Par Batch61474 ACS Benefit Solutions Non Par BatchTLU02 Administration Systems Research Corporation Non Par BatchCX076 Administrative Services Only (ASO) Par RT TRUE RT General TRUETLX97 ADN Administrators (MI) Par Batch TRUECCPSA Advantage by Superior Non Par Batch

93524 Advantage Dental Plan, Inc. Platinum RT TRUE RT General TRUE O

In-State, Credentialed

Providers Only TRUE83077 Advantek Benefit Administrators (Fresno, CA) Non Par Batch43168 Advantica (fka Essex Dental Benefits) Par RT TRUE95340 Adventist Health System West - Roseville, CA Non Par Batch60054 Aetna Par Batch TRUE RT Detailed TRUE W TRUE TRUE57604 Aetna Affordable Health Choices (SM) - SRC Par Batch TRUE RT Detailed TRUE W TRUE TRUE128WV Aetna Better Health of West Virginia Non Par Batch68246 Aetna DMO Par Batch TRUE RT Detailed TRUE W TRUE TRUE18014 Aetna Medicare Non Par BatchTLW02 Affordable Benefit Administrators, Inc. Non Par Batch58066 AFLAC of Georgia Non Par Batch52080 AFLAC of New York Non Par Batch91136 AGC International Union of Operating Engineers Local 701 (F07) Non Par Batch91136 AK United Food and Commercial Workers (AK UFCW) (F45) Non Par Batch

CX083 Alameda Alliance (Admin by LIBERTY Dental Plan)

Includes Claims for Liberty Dental Plans Previously

Submitted Under TPC12 Par Batch TRUE91136 Alaska Carpenters (F40) Non Par BatchAKEF1 Alaska Electrical Health & Welfare Fund Non Par Batch91136 Alaska Hotel Employees, Restaurant & Camp Employees (AK HERE) (F41) Non Par Batch91136 Alaska Laborers Construction Industry Health & Security Trust (F23) Non Par Batch91136 Alaska Machinists Health and Welfare Trust (F21) Non Par Batch91136 Alaska Pipe Trades U A Local 375 (F24) Non Par Batch91136 Alaska Public Employees Association (APEA/JESS Health & Welfare Trust) (F60) Non Par Batch44423 Alexian Brothers Community Services of TN a Mediture Payer Non Par BatchALH01 Aliera Healthcare Non Par BatchCXALC AllCare CCO Dental A Performance Health Technology Payer Non Par BatchTLU11 Allegiance Benefit Plan Management Non Par Batch93658 Alliance Coal Non Par Batch70106 Alliant Services (aka Voluntary Benefits Plan and US Life Ins Co) Non Par BatchTLX56 Allied Benefit Systems Non Par Batch91136 Allied Metal Crafts Security Plan Trust Fund (F18) Non Par Batch50503 Altus Dental Par BatchSTR01 Always Care Benefits Non Par Batch13343 Amalgamated Life / AliCare Par BatchTLU15 Amalgamated Life / AliCare Par BatchTLY53 Amalgamated Life / AliCare Par BatchTLU23 Ameriben Solutions (formerly IEC Insurance) Par Batch75240 American Administrative Group, Inc. (AAG) Non Par Batch42112 American Administrators (IA) Non Par BatchCX084 American Benefits Corp (Huntington, WV) Par BatchCX001 American Medical Security Par Batch TRUE S TRUE Must Enroll in EFT First TRUE16120 America's TPA Non Par Batch47009 Ameritas Life Insurance Company Par Batch TRUE TRUE38255 Amway Corporation / Dental Non Par Batch53085 Anchor Benefit Consulting Inc Non Par Batch

CX083 Anthem Health Plans - HMOD & HMOG (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE

CX083 Anthem Health Plans of Kentucky - OSB High & Low (Admin by LIBERTY Dental Plan)



CX083 Anthem Health Plans of Kentucky - PPOB & PPOD (Admin by LIBERTY Dental Plan)



CX083 Anthem Health Plans of Virginia - OSB High & Low (Admin by LIBERTY Dental Plan)



CX083 Anthem Health Plans of Virginia - PPOB & PPOD (Admin by LIBERTY Dental Plan)



CX083 Anthem HMO Colorado - HMO-B (Admin by LIBERTY Dental Plan)



Payer Identification Information Claims Processing Eligibility and Benefits Information Remittance Information

To submit to Payors not on this list, use Payor ID "06126"

and be sure to submit all required fields, including Payor Name and Complete Address. (C) 2014 Tesia ClearinghouseTesia Dental Payer Listing - Website (v 11.27.19).xlsx

1 of 16

Tesia Clearinghouse

www.Tesia.com



Tel: (800) 724-7240


eAttachments


Enrollment

Required Type

270s

Available

Enrollment

Required Type

Level of


835s

Available

Enrollment

Required

Paper EOBs

Shutoff

when

Enrolled ERA Notes

Accepts Tesia

eAttachments


CX083 Anthem Insurance - OSB High & Low (Admin by LIBERTY Dental Plan)



CX083 Anthem Insurance - PPOB & PPOD (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE34196 Apex Benefit Services Non Par Batch TRUE W TRUETLW68 APIPA (Arizona Physicians IPA) - Claims ONLY Par Batch TRUE S TRUE Must Enroll in EFT First TRUETLX06 APIPA (Arizona Physicians IPA) - Pre Determinations ONLY Par Batch TRUE S TRUE Must Enroll in EFT First TRUE44444 APWU Health Plan Non Par BatchARCMS AR Medicare Advantage Par Batch TRUE Detailed TRUE S TRUECXARC ARC Administrators Non Par BatchARGUS Argus Dental Plan (Encounters) Non Par Batch81883 Arkansas Municipal Health Benefit Fund Non Par Batch63240 ARM LTD Non Par Batch90475 Arrow Benefits Group Non Par BatchTLX61 ASEA / AFSCME Local 52 Par Batch TRUE RT General TRUETLU02 ASR Corporation Non Par BatchTLU02 ASR Health Benefits Non Par BatchASHC1 Assurant Health Supplemental Dental Non Par BatchTLX83 Assured Benefit Administrators Non Par Batch93221 Asuris Non Par Batch TRUEADN01 Atlantic Dental (ADI) Non Par BatchATPA1 ATPA - Associated Third Party Administrators (CA offices) Non Par BatchAULTC AultCare Dental (OH) Non Par Batch37242 Aultra Administrative Group Non Par Batch38259 Automated Benefit Services Non Par Batch37280 Automated Group Administration (AGA) Non Par Batch86098 Avesis Par Batch TRUEA2051 BAC Local 15 Welfare Fund (Kansas) Non Par BatchTLY50 Banner Health and Dental Plan Non Par Batch77078 Banner Plan Administration Non Par Batch

CHSBA Bay Area Automotive Group

Administered by Health Services Benefit

Administrators Non Par Batch

CHSBD Bay Area Delivery Drivers


Administrators Non Par Batch47198 BC - California (Wellpoint) Non Par Batch TRUE O TRUECBAL1 BCBS - Alabama Non Par Batch TRUE RT General TRUE W TRUE47570 BCBS - Alaska Par Batch TRUE RT General

TBX01 BCBS - Arizona

Includes BCBS Arizona FEP Claims Previously

Submitted Under Payer ID TLZ14 Non Par Batch TRUE W TRUE83470 BCBS - Arkansas Par Batch TRUE RT Detailed TRUE S TRUETFQ45 BCBS - Arkansas FEP Claims ONLY Non Par O Batch TRUE W84099 BCBS - Colorado Non Par Batch TRUE O TRUE65358 BCBS - Connecticut Non Par Batch TRUE O TRUE00700 BCBS - Connecticut (Family Plan) Non Par Batch TRUE O TRUE53287 BCBS - Delaware Non Par BatchTFL02 BCBS - Florida - FEDERAL CLAIMS Non Par BatchSB601 BCBS - Georgia Non Par Batch TRUE O TRUE

CB621 BCBS - Illinois

Includes BCBS Illinois FEP Claims Previously

Submitted Under Payer ID TLW12 Non Par BatchTLU89 BCBS - Indiana (FEP) Non Par Batch TRUE O TRUE84105 BCBS - Indiana (Anthem) Non Par Batch TRUE O TRUECBIA2 BCBS - Iowa (aka Wellmark Blue Dental) Non Par W BatchCBIA1 BCBS - Iowa (FEP and Farm Bureau ONLY) Non Par W BatchTLU90 BCBS - Kentucky (FEP) Non Par Batch TRUE O TRUE84105 BCBS - Kentucky (Anthem) Non Par Batch TRUE O TRUE

23739 BCBS - Louisiana

Includes BCBS - Louisiana FEP Claims Previously

Submitted Under Payer ID TLU05 Non Par S Batch TRUE RT General TRUE WBME01 BCBS - Maine (Anthem) Non Par Batch TRUE O TRUE

TLX88 BCBS - Maryland / CareFirst

Includes Claims for BCBS MD CareFirst Previously

Submitted under Payer IDs TLX85, TLX86, TLX87,

TLZ09, and TLU18 Non Par Batch

TRUE RT Detailed

TRUE S TRUE TRUECBMA1 BCBS - Massachusetts Non Par BatchBCBSM BCBS - Michigan Non Par BatchCBMI1 BCBS - Michigan (FEP Claims Only) Non Par BatchBXMN1 BCBS - Minnesota Non Par BatchTLU22 BCBS - Minnesota - Federal Employee Program (FEP) Non Par Batch

TBS01 BCBS - Mississippi

Includes BCBS Mississippi FEP Claims Previously

Submitted Under Payer ID TBS02 Non Par S Batch TRUE STBS03 BCBS - Mississippi (CHIP Claims ONLY) Par Batch TRUE S TRUE Must Enroll in EFT First TRUETBS04 BCBS - Mississippi (SPECIAL) Non Par Batch TRUE STLX52 BCBS - Missouri Non Par Batch TRUE O TRUETLU06 BCBS - Montana Non Par BatchTLU88 BCBS - Nebraska Non Par Batch



2 of 16

Tesia Clearinghouse

www.Tesia.com



Tel: (800) 724-7240


eAttachments


Enrollment

Required Type

270s

Available

Enrollment

Required Type

Level of


835s

Available

Enrollment

Required

Paper EOBs

Shutoff

when

Enrolled ERA Notes

Accepts Tesia

eAttachments


84101 BCBS - Nevada Non Par Batch TRUE O TRUEBNH01 BCBS - New Hampshire (Anthem) Non Par Batch TRUE O TRUE84100 BCBS - New Mexico Non Par Batch61473 BCBS - North Carolina Non Par Batch61472 BCBS - North Carolina (FEP Program & Health Choice for Children) Non Par Batch52133 BCBS - North Carolina (Salt Lake City, UT ONLY) Par Batch TRUE RT General TRUE S TRUE Must Enroll in EFT First TRUE84105 BCBS - Ohio (Anthem) Non Par Batch TRUE O TRUETLU91 BCBS - Ohio (FEP) Non Par Batch TRUE O TRUETBOK1 BCBS - Oklahoma Non Par Batch

CB870 BCBS - Rhode Island

FEP claims should NOT be submitter under this

Payer ID - Please use Payer ID RIFEP Par BatchTRUE RT Detailed

TRUE STRUE

RIFEP BCBS - Rhode Island FEP

Only FEP claims should be submitted under this

Payer ID Non Par BatchTRUE RT Detailed

TRUE W Only in-state providers may

enroll for ERA.

38520 BCBS - South Carolina

Includes BCBS - South Carolina FEP Claims

Previously Submitter Under Payer ID TLW74 Non Par BatchTLY09 BCBS - South Dakota Non Par W BatchCBTN1 BCBS - Tennessee (Claims ONLY - no PTE) Non Par W Batch TRUE RT General TRUE WL84980 BCBS - Texas Non Par Batch84103 BCBS - Virginia (Trigon) Non Par Batch TRUE O TRUE47570 BCBS - Washington Par Batch TRUE RT GeneralTLY47 BCBS - Washington DC Non Par Batch TRUE RT Detailed TRUE S TRUE TRUE00301 BCBS - Western New York Par Batch TRUE W

39141 BCBS - Wisconsin

Includes BCBS WI Claims Previously Submitted

Under Payer ID CB950 & Claim Management

Services Claims Previously Submitted Under Payer

ID CMS01 Non Par Batch TRUE O TRUETLX12 BCBS - Wyoming Par Batch TRUE S TRUEBBMDQ BCBS MI / BCBS MI Medicare Advantage Non Par Batch49153 BCI Administrators, Inc. Par BatchBEAM1 Beam Dental Par Batch60054 Bell Atlantic Par Batch TRUE RT Detailed TRUE W TRUE TRUE23210 BeneCare Dental Plan Par Batch TRUE41205 Benefit Administration Services Non Par BatchTFQ64 Benefit Administrative Systems (BAS) (Homewood, IL) Non Par Batch25145 Benefit Coordinators Corporation (Pittsburgh, PA) Non Par BatchR7003 Benefit Inc. (MN) Non Par Batch TRUE RT Detailed TRUE S TRUE43471 Benefit Management / Inetico Par Batch36459 Benefit Management Group (NV) Non Par Batch48611 Benefit Management of Kansas Non Par BatchTLU45 Benefit Management Services (NC) Non Par Batch37212 Benefit Management Systems (MS) Non Par Batch19753 Benefit Plan Administrators Inc Non Par Batch

39081 Benefit Plan Administrators, Inc. (Eau Claire, WI)

Includes Custom Benefit Administrators Claims

Previously Submitter Under Payer ID 39170 and 3P

Administrator Claims Previously Submitted Under

Payer ID 20413 Par Batch TRUE07000 Benefits Inc (Construction Suppliers Group only) Non Par Batch TRUE RT Detailed TRUE S TRUEBMX01 BeneMax Non Par Batch95604 Best Life & Health Insurance Company Non Par BatchTLY26 Blue Advantage (BCBS of AR) Par Batch TRUE RT Detailed TRUE S TRUE47163 Blue Cross Blue Shield of Kansas Non Par Batch TRUE W47171 Blue Cross Blue Shield of Kansas City Non Par Batch TRUE W

CX083 Blue Cross Blue Shield of Wisconsin - PPOD (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUEBCD01 Blue Cross Dental (MD) / Dominion / Capital Blue Cross Par Batch TRUE RT General TRUE

CX083 Blue Cross of California - OSB High & Low (Admin by LIBERTY Dental)



CX083 Blue Cross of California - Plan SS10 & SS20 (Admin by LIBERTY Dental Plan)



CX083 Blue Cross of California - PPOA (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUECBID1 Blue Cross of Idaho Non Par W Batch TRUE W52133 Blue Shield of California Par Batch TRUE RT General TRUE S TRUE Must Enroll in EFT First TRUEBSCA2 Blue Shield of California (FEP Only) Non Par BatchCB865 Blue Shield of Pennsylvania (Camp Hill) Platinum RT TRUE RT Detailed TRUE S TRUECBPA2 Blue Shield of Pennsylvania - Dental Plus (UCCI) Platinum RT TRUE RT Detailed TRUE S TRUE36609 Boilermakers National Health & Welfare Fund (Int'l Brotherhood of Boilermakers) Non Par BatchTLX71 Bollinger Insurance Par Batch74237 Boon-Chapman Benefit Administrators Inc Non Par Batch04210 Boston University Dental Health Plan Non Par BatchCX028 Bridgeport LLC of Missouri (St. Charles, MO) Par RT TRUEBRIDG Bridgespan Health Non Par Batch TRUE51037 Brokerage Concepts Non Par Batch



3 of 16

Tesia Clearinghouse

www.Tesia.com



Tel: (800) 724-7240


eAttachments


Enrollment

Required Type

270s

Available

Enrollment

Required Type

Level of


835s

Available

Enrollment

Required

Paper EOBs

Shutoff

when

Enrolled ERA Notes

Accepts Tesia

eAttachments


CX032 Brokers National Par Batch TRUE TRUE00800 BS Northeastern New York Par Batch TRUE W61301 Businessmen's Assurance (NE) Par Batch TRUE TRUE42150 Butler Dental (IA) Non Par BatchCAS89 C.A.S. Benefit Plans Par Batch

CX083 Cal Optimal - OneCare (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE71057 Cannon Cochran Management Services, Inc. (LA Plan ONLY) Non Par BatchCBC01 Capital Blue Cross (CBC) / Blue Cross Dental (MD) Par Batch TRUE RT General TRUE68011 Capitol Administrators Non Par BatchCX095 Capitol Dental Plan (OR) Non Par BatchCAPHP Caprock Health Plans Non Par Batch

CX083 Care 1st Health Plan Medicare Advantage (Admin by LIBERTY Dental Plan)



CX083 Care 1st PHP LA & San Bernadino County (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUETLY44 Careington Corporation Par Batch TRUE93975 CareOregon Non Par BatchGACS1 Caresource - GA Par BatchKYCS1 Caresource - KY Par Batch TRUEWVCS1 Caresource - WV Par BatchCKOH2 Caresource (OH) Par Batch INCS1 CareSource of IN (Just4Me) Par BatchTLU48 Carolina Summit Healthcare Inc Non Par BatchTFQ25 Carpenters Combined Funds (PA) Platinum RT TRUE RT Detailed TRUE S TRUETLW16 Carpenter's Health & Welfare Fund (Philadelphia, PA) Par Batch TRUETLW06 Carpenters Health and Welfare Trust Funds (St. Louis, MO) Par RT TRUE RT Detailed TRUECHA01 Cascade Comprehensive Care Inc Non Par Batch37060 Caterpillar Inc Par Batch TRUE S TRUE Must Enroll in EFT First TRUE03036 CBA Blue Dental / Emp Benefit Plan Admin Non Par BatchTLZ03 CCPOA Benefit Trust Fund Non Par iBatch88022 CDS Group Health (NV) Non Par Batch91136 Cement Masons & Plasterers Health & Welfare Trust (F16) Non Par BatchTLU51 Central PA Teamsters Health & Welfare Fund Par Batch TRUE S TRUE TRUETLW76 Central Reserve Life Insurance Company Non Par Batch36215 Central States Health & Welfare Fund (IL) Par Batch TRUE

84147 CHAMPVA - HAC

CHAMPVA-HAC is not associated with and does not

process claims for TRICARE (fka CHAMPUS) Non Par BatchTLU92 Chesterfield Resources, Inc. Non Par BatchTLY40 Chicago Regional Council of Carpenters Par Batch TRUE84147 Children of Women Vietnam Veterans - VA HAC Non Par Batch60054 Choice Plus (TRW) Par Batch TRUE RT Detailed TRUE W TRUE TRUE38308 Christian Brothers Services (CBS Health Benefits) Non Par Batch

62308 CIGNA

Includes Cigna Flex Care (NM) Claims Previously

Submitted Under Payer ID TLX70 Par Batch TRUE S

Paper remittances turned off if

enrolled in EFT.

10050 CIGNA (DHMO) Par Batch TRUE S


enrolled in EFT.TLU52 Citizens Security Life Insurance Co Non Par Batch38219 ClaimChoice Administrators Non Par Batch89461 Claims Bridge North Non Par Batch44219 Claims Bridge NW Non Par Batch55731 Claims Bridge South Non Par BatchTLU53 Combined Insurance Service Non Par Images27905 Community Health Alliance of TN Non Par Batch75261 Community Health Electronic Claims (CHEC/Webta) Non Par Batch

CX083 Community Insurance - HMOA & PPOB (Admin by LIBERTY Dental Plan)



CX083 Community Insurance - PPOD & PPOF (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE48005 Companion Life Non Par Batch77828 Companion Life Non Par BatchCX021 CompBenefits (Chicago, IL) Non Par BatchPBGSM Comprehensive Benefit Administrators Non Par BatchTLW14 Comprehensive Benefits & Claims Administrators Non Par Batch00720 Comprehensive Care Services Non Par BatchWT011 Comprehensive Healthcare Options Non Par Batch10166 Comprehensive Medical and Dental Program CMDP Non Par Batch37307 Connecticut Carpenters Health Fund Par Batch TRUE RT Detailed TRUE S TRUE TRUE

62308 Connecticut General (CIGNA) Par Batch TRUE S


enrolled in EFT.37135 Consociate Group Non Par Batch61305 Consolidated Group Dental Non Par Batch45321 Consumers Choice Health Plan - State of SC Non Par Batch



4 of 16

Tesia Clearinghouse

www.Tesia.com



Tel: (800) 724-7240


eAttachments


Enrollment

Required Type

270s

Available

Enrollment

Required Type

Level of


835s

Available

Enrollment

Required

Paper EOBs

Shutoff

when

Enrolled ERA Notes

Accepts Tesia

eAttachments


52132 Cooperative Benefit Administrators Non Par BatchTLX80 CORE Administrative Services Non Par BatchTFQ74 CoreFive Par Batch TRUE75136 CoreSource AR Non Par Batch41045 CoreSource AZ MN Non Par Batch48117 CoreSource KC (fka FMH Benefit Services Inc) Non Par Batch35182 CoreSource MD PA IL Non Par Batch35180 CoreSource NC IN Non Par Batch

35183 CoreSource OH (Clinton, IA)

Includes Coresource IA Claims Previously Submitted

Under Payer ID TFQ37 Non Par Batch58102 Covenant Administrators Non Par Batch25148 Coventry Health Care of Georgia Non Par Batch87043 Coventry Healthcare National Network Non Par Batch37320 Creative Plan Administrators (MD) Non Par BatchTLU54 Crescent Dental Non Par Batch56213 Crescent Health Solutions Non Par Batch20572 Crowe Paradis Services Corp. Non Par BatchCX054 CSEA Employee Benefit Fund Par Batch TRUETLU56 CT Carpenters Health Fund Par Batch TRUE RT Detailed TRUE S TRUE TRUE42141 CTI Administrators Non Par BatchTFQ58 Custom Design Benefits Par Batch60054 CustomCare (Southwest Bell Execs) Par Batch TRUE RT Detailed TRUE W TRUE TRUETLZ04 Cypress Ancillary Benefits Par Batch07689 Cypress Benefit Admin Par Batch39199 Cypress Dental Par Batch

06172 Dart Management Corporation

Includes Claims for Dart Container Corporation

Previously Submitted Under Payer ID TLX43 Non Par BatchHSP01 DC 37 Health and Security Non Par BatchDDS01 DDS Inc Non Par Batch07035 DeCare Dental Health Insurance Non Par Batch TRUE RT Detailed TRUE W TRUE TRUEDEHI1 Delta Dental - Hawaii / Hawaii Dental Services Non Par RT TRUE02027 Delta Dental - Northeast (ME, NH, VT) Par Batch TRUE RT Detailed TRUETLZ34 Delta Dental Health Families Par Batch TRUE RT Detailed TRUE S TRUE TRUE94276 Delta Dental Insurance Company / DDIC Par Batch TRUE RT Detailed TRUE S TRUE TRUE94276 Delta Dental of Alabama Par Batch TRUE RT Detailed TRUE S TRUE TRUECDOR1 Delta Dental of Alaska Par Batch TRUE RT Detailed TRUE W TRUE86027 Delta Dental of Arizona Par Batch TRUEDELAR Delta Dental of Arkansas Par Batch TRUE RT Detailed TRUE S TRUE77777 Delta Dental of California Par Batch TRUE RT Detailed TRUE S TRUE TRUE84056 Delta Dental of Colorado Par Batch TRUE22189 Delta Dental of Connecticut Par Batch TRUE RT Detailed TRUE S TRUE TRUE51022 Delta Dental of Delaware Par Batch TRUE RT Detailed TRUE S TRUE TRUE94276 Delta Dental of Florida Par Batch TRUE RT Detailed TRUE S TRUE TRUE94276 Delta Dental of Georgia Par Batch TRUE RT Detailed TRUE S TRUE TRUE82029 Delta Dental of Idaho Platinum Batch TRUE47598 Delta Dental of Illinois Group Plans Par Batch TRUEIDIND Delta Dental of Illinois Individual Plan Par Batch TRUE

DELTI Delta Dental of Indiana

Includes claims for Indiana Carpenters Welfare &

Pension Fund Previously Submitted Under Payer ID

ICW01.

Par

RT TRUE RT Detailed TRUE S TRUECDIA1 Delta Dental of Iowa Par Batch TRUECDIAM Delta Dental of Iowa - Government Programs Par Batch TRUE RT Detailed TRUECDKS1 Delta Dental of Kansas Par Batch TRUE RT Detailed TRUE TRUECDKY1 Delta Dental of Kentucky Par RT TRUE RT Detailed TRUE S TRUE94276 Delta Dental of Louisiana Par Batch TRUE RT Detailed TRUE S TRUE TRUE02027 Delta Dental of Maine Par Batch TRUE RT Detailed TRUE23166 Delta Dental of Maryland Par Batch TRUE RT Detailed TRUE S TRUE TRUE04614 Delta Dental of Massachusetts Non Par BatchDELTA Delta Dental of Michigan Par RT TRUE RT Detailed TRUE S TRUECDMN1 Delta Dental of Minnesota Non Par Batch TRUE RT Detailed TRUE S TRUE94276 Delta Dental of Mississippi Par Batch TRUE RT Detailed TRUE S TRUE TRUE43090 Delta Dental of Missouri Par RT TRUE RT Detailed TRUE94276 Delta Dental of Montana Par Batch TRUE RT Detailed TRUE S TRUE TRUE07027 Delta Dental of Nebraska Par Batch TRUE RT Detailed TRUE S TRUE94276 Delta Dental of Nevada Par Batch TRUE RT Detailed TRUE S TRUE TRUE02027 Delta Dental of New Hampshire Par Batch TRUE RT Detailed TRUE22189 Delta Dental of New Jersey Par Batch TRUE RT Detailed TRUE S TRUE TRUEDELTM Delta Dental of New Mexico Par RT TRUE RT Detailed TRUE S TRUE11198 Delta Dental of New York Par Batch TRUE RT Detailed TRUE S TRUE TRUE56101 Delta Dental of North Carolina Par RT TRUE RT Detailed TRUE S TRUECDND1 Delta Dental of North Dakota Non Par Batch TRUE RT Detailed TRUE S TRUEDELTO Delta Dental of Ohio Par RT TRUE RT Detailed TRUE S TRUEDELOK Delta Dental of Oklahoma Par Batch TRUE RT Detailed TRUE



5 of 16

Tesia Clearinghouse

www.Tesia.com



Tel: (800) 724-7240


eAttachments


Enrollment

Required Type

270s

Available

Enrollment

Required Type

Level of


835s

Available

Enrollment

Required

Paper EOBs

Shutoff

when

Enrolled ERA Notes

Accepts Tesia

eAttachments


CDOR1 Delta Dental of Oregon (fka Moda Health / Oregon Dental Services) Par Batch TRUE RT Detailed TRUE W TRUE23166 Delta Dental of Pennsylvania Par Batch TRUE RT Detailed TRUE S TRUE TRUE66043 Delta Dental of Puerto Rico Non Par Batch05029 Delta Dental of Rhode Island Par Batch43091 Delta Dental of South Carolina Par RT TRUE RT Detailed TRUE54097 Delta Dental of South Dakota Par Batch TRUEDELTN Delta Dental of Tennessee Par RT TRUE RT Detailed TRUE S TRUE94276 Delta Dental of Texas Par Batch TRUE RT Detailed TRUE S TRUE TRUE94276 Delta Dental of Utah Par Batch TRUE RT Detailed TRUE S TRUE TRUE02027 Delta Dental of Vermont Par Batch TRUE RT Detailed TRUECDVA1 Delta Dental of Virginia Non Par Batch91062 Delta Dental of Washington (aka Washington Dental Services) Par Batch TRUE RT Detailed TRUE S TRUE Requires EFT TRUE52147 Delta Dental of Washington DC Par Batch TRUE RT Detailed TRUE S TRUE TRUE31096 Delta Dental of West Virginia Par Batch TRUE RT Detailed TRUE S TRUE TRUE39069 Delta Dental of Wisconsin Par Batch TRUE07025 Delta Dental of Wyoming Par Batch TRUE94235 Delta Health Systems (CA) Non Par BatchCDCA2 DeltaCare USA / Private Medical Care (PMI) - CLAIMS ONLY Par Batch TRUE RT Detailed TRUE S TRUE TRUECDCAP DeltaCare USA / Private Medical Care (PMI) - ENCOUNTERS ONLY Par Batch TRUE RT Detailed TRUE S TRUE TRUECX049 Denex/SG Non Par Batch52133 Dental Benefit Providers Par Batch TRUE RT General TRUE S TRUE Must Enroll in EFT First TRUEDCP01 Dental Care Plus (DCP) Par Batch TRUE46278 Dental Health & Wellness Non Par BatchDHSV1 Dental Health Services Par Batch TRUEDNOAT Dental Network of America (DnOA) Non Par Batch39148 Dental Professionals of Wisconsin (fka Southeast Dental Associates (SEDA)) Non Par BatchDSL01 Dental Select, Inc. Par Batch TRUECX014 DentaQuest - Medicaid (fka Doral Dental Plan) Non Par Batch88888 Dentegra Par Batch TRUE RT Detailed TRUE S TRUE TRUE94146 Denti-Cal (Medicaid of California) Non Par I Batch TRUE I TRUEUTUDD Dentist Direct Par BatchDESAZ Department of Economic Security Non Par BatchTFQ56 Deseret Mutual Benefit Administrators (DMBA) Non Par S Batch TRUE SUTUDQ Direct Care Admin Par BatchCX040 Diversified Administration Corporation Par BatchDOM01 Dominion Dental USA (DHMO and Commercial) Par Batch TRUE RT General TRUEDRAD1 DR Administrative Services, Inc Par Batch35186 Dunn & Associates Benefit Administrators Inc Par BatchTLZ28 Eastern Life & Health Par Batch TRUE TRUE

CX083 EasyChoice Health Plan (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE81039 EBMS Employee Benefit Management Services Inc Non Par Batch08754 Eddy SeniorCare Non Par BatchTLU59 Educators Mutual Insurance Assoc (EMI) Non Par Batch TRUE TRUE73288 EHI Non Par Batch03964 Elderwood Health a Mediture Payer Non Par Batch13551 Emblem Health (Group Health Inc) Platinum Batch TRUE RT GeneralEMBDQ Emblem Health Medicaid (Emblem Dentaquest) Non Par Batch73288 EMPHESYS Employers Health of Wisconsin Non Par Batch55093 Empire Blue Cross Blue Shield (NY) Non Par Batch TRUE RT Detailed TRUE W TRUE TRUE

CX083 EmpireHealthChoice Assurance - OSB Low & PPOB (Admin. by LIBERTY Dental Plan)



CX083 EmpireHealthChoice HMO (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUECX025 Employee Benefit Management Corp (EBMC) (OH) Non Par Batch38241 Employee Benefit Concepts (Farmington Hills, MI) Non Par Batch03036 Employee Benefit Plan Administration, Inc. (EBPA) Non Par Batch42149 Employee Benefit Systems of IA Par Batch37257 Employee Benefits Consultants (EBC INC - OH) Non Par Batch60221 Employee Benefits Services Inc Non Par BatchCX031 Employee Plan Services, Inc. (EPSI) Non Par Batch35112 Employee Plans, LLC Non Par Batch75232 Employers Direct Health Non Par Batch73288 Employers Health Insurance of Wisconsin (EHI) (EMPHESYS) Non Par Batch59297 Employers Mutual, Inc. Non Par BatchWT016 Encara Par Batch TRUECX037 EPSI Dental II (fka Capital Dental) Non Par Batch

62308 EQUICOR Par Batch TRUE S


enrolled in EFT.74234 ERISA / CompuSys Par Batch TRUE34108 ES Beveridge and Associates Par Batch34159 E-V Benefits Management, Inc. Non Par BatchMNM01 Everence (fka Mennonite Mutual Aid) Non Par Batch



6 of 16

Tesia Clearinghouse

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Tel: (800) 724-7240


eAttachments


Enrollment

Required Type

270s

Available

Enrollment

Required Type

Level of


835s

Available

Enrollment

Required

Paper EOBs

Shutoff

when

Enrolled ERA Notes

Accepts Tesia

eAttachments


93240 Evergreen Health Co-op Non Par BatchEXC01 Excellus BlueCross BlueShield Rochester, Finger Lakes, Utica, Watertown Platinum RT TRUE RT General TRUEEXC02 Excellus BlueCross BlueShield Central NY, Syracuse, Utica Platinum RT TRUE RT General TRUEEXC01 Excellus, Inc. Platinum RT TRUE RT General91136 Fairbanks North Star Borough (F62) Non Par BatchCX096 Family Dental Non Par BatchCXFMC FamilyCare CCO A Performance Health Technology Payer Non Par BatchTLY84 FCE Benefit Administrators (TX) Non Par Batch

71056 Fed Ex Freight East Par Batch TRUE S


enrolled in EFT.

TLU64 FedEx Freight Health Benefit Par Batch TRUE S


enrolled in EFT.BCAFD FEP Blue Dental (Decare) Non Par Batch TRUE RT Detailed TRUE W TRUE TRUETLU69 Fidelio Insurance Co Par Images TRUE72630 First Ameritas Life Insurance Corporation of New York Par Batch TRUE TRUETLZ41 First Commonwealth (IL) Par Batch TRUE RT Detailed TRUECX090 First Continental Life & Accident Par Batch TRUETLU63 First Dental Health (FDH) Non Par BatchTFZ08 First Plan Blue Non Par Batch TRUE RT Detailed TRUE S TRUE71005 First Reliance Standard (NY Business) Par Batch TRUE TRUEDDNJF Flagship - DeltaCare (DDNJ) Par Batch TRUE S TRUER7004 Flex Compensation Non Par Batch TRUE RT Detailed TRUE S TRUE60054 FlexCare Par Batch TRUE RT Detailed TRUE W TRUE TRUETLU70 Flexible Benefit Fund Par Batch TRUE RT General TRUE76031 Florida Combined Life (BCBS of FL) Par Batch TRUE RT Detailed TRUE S TRUE60054 Florida Power & Light Par Batch TRUE RT Detailed TRUE W TRUE TRUE25059 Forest County Potawatomi Non Par BatchTLU19 Formula Dental Par Images TRUE70408 Fortis Benefits Insurance Company Par Batch TRUETLU72 Foundation Benefits Administration Non Par BatchTLU71 Fox Valley Welfare Fund Non Par Batch

64069 Fox-Everett Inc

Includes Fox-Everett (MS) Claims Previously

Submitted Under Payer ID TLY81 Non Par BatchCX041 Fraternal Order of Police -- Dental Division Non Par BatchTLZ18 Frates Benefit Administrators Par Batch59204 Fringe Benefit Coordinators of FL Non Par Batch37283 Gallagher Benefit Administrators Non Par Batch96938 Gateway Health Plan Non Par BatchGCU01 GCU Local 8-M & 96B Health & Welfare Fund Non Par Batch67814 GEGLAC - G.E. Group Life Assurance Company - Dental Non Par Batch44054 GEHA Employee Program Non Par Batch67814 Genworth Life and Health Insurance Company Non Par BatchTLU74 Gettysburg Insurance Services Non Par Batch80314 GIC (Indemnity Plan) Non Par Batch TRUE O TRUE07205 Gilsbar, Inc Non Par Batch

CX083 Golden State Health Plan (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUEGWD01 Golden West Dental Non Par Batch TRUE O TRUE57254 Government Employees Health Association (GEHA) Non Par Batch80705 Great-West Healthcare Non Par Batch63665 Great-West Healthcare (fka General American Life Insurance Company) Non Par BatchTLY75 Group & Pension Administrators (GPA) Par Batch36338 Group Administrators LTD Par BatchCX036 Group Dental Service of Maryland, Inc. / GDS-MD Non Par Batch37276 Group Insurance Service Center, Inc. Non Par Batch66701 Group Marketing Services Inc Non Par Batch37086 Group Plan Solutions Non Par Batch64246 Guardian Life Insurance Company Par Batch TRUE RT Detailed TRUEGI813 Guardian Managed DentalGuard (Individual Market) Par Batch TRUE RT Detailed TRUE99943 Gulf Guaranty / MedPlus Non Par Batch47738 Hamaspik Choice a Mediture Payer Non Par Batch59142 Harrington Benefit Services, Inc. (fka HealthPlan Services Oklahoma) Non Par Batch59143 Harrington Health Colonial Dental Non Par BatchTFQ61 Hawaii Medical Assurance Association (HMAA) Non Par Batch86066 Hawaii-Mainland Administrators Non Par BatchTPC08 Hawaii-Western Management Group (HWMG) Non Par Batch82018 HCS - Health Claims Service Non Par Batch

TLX24 Health Benefit Claims Dept Par Batch TRUE S


enrolled in EFT.22100 Health Choice Integrated Care Non Par Batch

16112 Health Economics Group, Inc.

Includes Claims for Dental Claims Payers (NY)

Previously Submitted Under TFQ14 Platinum Batch TRUE RT GeneralTLW61 Health First TPA Non Par Batch



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CX083 Health Net 21 - LA & Sacramento (Admin by LIBERTY Dental Plan)



CX083 Health Net Healthy Families A, B & C (Admin by LIBERTY Dental Plan)



CX083 Health Net Los Angeles PHP (Admin by LIBERTY Dental Plan)



CX083 Health Net Sacramento GMC (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUECX009 Health Partners of Minnesota (Commercial Plan) Non Par W BatchCX010 Health Partners of Minnesota (Minnesota Medical Assistance) Non Par W Batch59140 Health Plan Services (FL) Non Par BatchCX055 Health Plans, Inc. Non Par BatchCX019 Health Resources Incorporated (HRI) Par Batch TRUEHTD99 Health Traditions - MMSI Non Par BatchHMA01 Healthcare Management Administrators, Inc. (HMA) Non Par BatchHCP01 HealthCare Payer’s Coalition Non Par Batch71064 HealthChoice Par Batch62179 HealthChoice AZ Non Par Batch46221 HealthChoice Insurance Non Par Batch22521 HealthChoice of Oklahoma Non Par Batch85729 HealthComp (CA) Par Batch20356 HealthE Exchange Inc Non Par Batch95213 HealthEdge Administrators Non Par Batch56144 Healthgram Inc (fka Primary Physician Care Inc) Non Par Batch59226 HealthMarkets (fka MEGA Life & Health Insurance Co) Par Batch TRUE52133 HealthNet of Oregon Par Batch TRUE RT General TRUE S TRUE Must Enroll in EFT First TRUE55204 HealthNow NY Par Batch TRUE W

11271 Healthplex Inc

Includes Claims Previously Submitted Under Payer

ID 00004 and TLZ11. Par Batch TRUE TRUE71063 HealthScope Benefits, Inc. (fka CNA Health Partners of Arkansas) Par BatchCXHSC HealthShare CCO A Performance Health Technology Payer Non Par Batch37256 Healthsmart Benefit Solutions fka Mutual Assurance Administrators Inc Non Par Batch87815 HealthSmart Benefit Solutions (fka Acordia National, Wells Fargo TPA) Non Par Batch31172 HealthTrans Non Par Batch

CX083 Healthy Alliance Life Insurance - PPOB (Admin by LIBIRTY Dental Plan)


Submitted Under TPC12 Par Batch TRUECARRS Healthy Michigan Dental (Carriers TPA) Non Par BatchHGL01 Heavy & General Laborers Non Par Batch

HMSA1 HMSA (Hawaii Medical Services) - Commercial

Includes Claims for Benefit Services of Hawaii

Previously Submitted Under Payer ID TLZ27 Par Batch TRUE RT Detailed TRUE S TRUE88023 Hometown Health Plans Non Par BatchHZFEP Horizon BCBS NJ FEP Claims Non Par Batch22099 Horizon Blue Cross Blue Shield of New Jersey Non Par Batch TRUE W TRUE TRUE22099 Horizon Healthcare of New York Non Par Batch TRUE W TRUE TRUE91136 Hotel Employees Restaurant Employees Health Trust (HERE) (F19) Non Par Batch37224 HSBS Memphis (fka Pitman & Associates) Non Par Batch73288 Humana Dental Non Par Batch22175 I.E. Shaffer (West Trenton, NJ) Non Par BatchIAT01 IATSE - International Association of Theatrical Stage Employees Non Par BatchA1464 IBEW Local 364 Non Par BatchA1317 IBEW Local 38 Par RT TRUE RT Detailed TRUE S TRUEA1461 IBEW Local 461 Non Par BatchA4681 IBEW Local 481 Non Par Batch72436 Immanuel Pathways - Central Iowa Non Par Batch35416 Immanuel Pathways - Nebraska Non Par Batch53534 Immanuel Pathways - SW Iowa Non Par Batch54763 Independence Administrators previosuly listed as AmeriHealth Administrators Non Par Batch89070 Independence Blue Cross Dental Plan – BlueExtraSM Platinum RT TRUE RT Detailed TRUE S TRUECX070 Indiana Children's Special Health Care Non Par Batch35107 Indiana Teamsters Health Benefit Funds (fka Local 135 Health Benefits Fund) Non Par Batch31172 Innovate Benefit Administrators Non Par Batch40025 Innovation Health Non Par Batch38255 Insight Benefit Administrators Non Par BatchTLY73 Insurance Administrators of America Non Par Batch13315 Insurance Design Administrators (Oakland NJ) Non Par Batch15688 Insurance Management Services Non Par Batch74385 Insurance Systems Inc Par Batch TRUEIAC01 Insurers Administrative Corp / IHC Administrative Corp Non Par Batch51020 INTEGRA Administrative Group Par BatchTLW56 Interactive Medical Systems, Inc. Non Par Batch36342 IPMG Employee Benefits Non Par Batch42600 Itasca Medical Care Non Par BatchCXJAS Jensen Administrative Services, Inc. Non Par Batch



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TLW64 JI Specialty Services Company Non Par Batch38310 John Morrell Company- AHBPA Non Par Batch

CHSJT Joint Benefit Trust


Administrators Non Par Batch34136 JP Farley Corporation Non Par BatchCX073 Kaiser Permanete Dental Choice Non Par Batch40137 Kalos Health Non Par Batch57038 Kanawha Insurance Company (Lancaster and Greenville, SC) Non Par BatchA2032 Kansas City Laborers Welfare Fund Non Par BatchTKC01 Kansas City Life Insurance Company / KCL Group Benefits Non Par Batch95279 Keenan Associates Non Par Batch73100 Kempton Company (OK) Par Batch73100 Kempton Group Administrators Par Batch77894 Kentucky Health Co-Op Non Par Batch34145 Klais & Company Non Par Batch

CX083 LA Care Health Plan (Admin by LIBERTY Dental Plan)



CX083 Liberty Dental Plan


Submitted Under TPC12 Par Batch TRUE25922 LIFE Armstrong Non Par Batch25924 LIFE Beaver & Lawrence Non Par Batch25923 LIFE Butler Non Par Batch71498 Life Circles PACE a Mediture Payer Non Par Batch78140 Life Insurance Company of Boston & New York (Student Insurance) Non Par BatchCX047 LifeRe Par Batch TRUE TRUEEBS01 LifeTime Benefits (fka EBS Benefit Solutions) Par Batch TRUE RT General TRUEEBSRM LifeTime Benefits (fka EBS-RMSCO Inc) Par Batch TRUE RT General TRUE16117 LifeTime Benefits (fka RMSCO) Par Batch TRUE RT General TRUETFQ89 Lifewise Health Plan of Oregon Non Par BatchJPF01 Lincoln Finacial / Jefferson Pilot / Guarantee Life Insurance Company Par BatchCX061 Lincoln Financial Group (Lincoln National Life) Par Batch73288 Lincoln National (WI) (in Madison or Green Bay) Non Par BatchLCB01 Line Construction Benefit (Line Co) Non Par BatchTRW01 Local 136 Health & Welfare Fund Non Par Batch84041 Local 137 Operating Engineers Welfare Fund Non Par BatchIAHFI Local 17 - Intl Assoc of Heat & Frost Insulators Non Par Batch91136 Locals 302 & 612 of the International Union of Operating Engineers (F12) Non Par BatchCB752 Lockard & Williams Par Batch62413 Mail Handlers Benefit Plan (Also known as Mailhandlers/CAC) Non Par Batch

65030 Managed Care of North America (MCNA)

Includes Medicaid of LA Claims Previously Submitted

Under Payer IDs CKLA1 and CKLA2. Par Batch60054 Marriott Par Batch TRUE RT Detailed TRUE W TRUE TRUECX098 Masonry Institute/ Administrative D.C. No.1 Welfare Fund Non Par BatchTLZ30 MBA Benefit Administrators (UT) Non Par Batch87065 MBA of Wyoming Non Par Batch

56205 MBS (Medcost Benefit Services)

Includes claims previously submitted under Payer ID

TLW63. Non Par Batch31149 McGregor PACE Non Par Batch

CX083 MD Care Health Plan (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUEEM284 MED3000 CMS Safety Net Non Par BatchEM843 MED3000 CMS Title 19 Reform Non Par BatchEM205 MED3000 CMS Title 21 Non Par BatchEM039 MED3000 Pediacare Title 19 Non Par BatchEM522 MED3000 Pediacare Title 21 Non Par Batch74323 MedBen (Newark, OH) Non Par Batch

CX026 MEDICA of Minnesota

Includes Claims Submitted Under Payer ID 07031 &

MEDIC Non Par Batch TRUE RT Detailed TRUE S TRUEMEPUB MEDICA Public Programs (A MN Medical Assistance Plan) Non Par Batch TRUE RT Detailed TRUE S TRUECKAL1 Medicaid of Alabama Non Par Batch TRUE WCKAK1 Medicaid of Alaska Non Par F BatchTLU09 Medicaid of Arizona Non Par BatchCKAR1 Medicaid of Arkansas Non Par BatchCKCO1 Medicaid of Colorado Non Par BatchCKCT1 Medicaid of Connecticut Non Par Batch TRUE TRUECKDE1 Medicaid of Delaware Non Par Batch TRUE OMCDC1 Medicaid of District of Columbia (DC) Non Par W BatchCKFL1 Medicaid of Florida Non Par W Batch TRUE FCKGA2 Medicaid of Georgia (HFP) Includes Claims Submitted Under Payer ID CKGA1 Non Par O Batch TRUE O TRUETMCHI Medicaid of Hawaii Non Par BatchCKID1 Medicaid of Idaho Non Par Batch CX014 Medicaid of Illinois Non Par BatchCKIN1 Medicaid of Indiana Non Par Batch TRUE O



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CKIA1 Medicaid of Iowa Non Par O Batch CKKS1 Medicaid of Kansas Non Par Batch TRUE WCKKY3 Medicaid of Kentucky Region #3 (Doral Dental) Non Par BatchTLU10 Medicaid of Kentucky Region #5 (KY Health Choice / Select) Non Par Batch TRUE WCKME1 Medicaid of Maine Non Par BatchMCMD1 Medicaid of Maryland (Dept of Health & Mental Hygiene) Non Par BatchCKMA1 Medicaid of Massachusetts Non Par BatchCKMI1 Medicaid of Michigan Non Par O Batch TRUE WCKMN1 Medicaid of Minnesota (Minnesota Medical Assistance) Non Par W BatchCKMS1 Medicaid of Mississippi Non Par F BatchCKMO1 Medicaid of Missouri Non Par O Batch TRUE OCKMT1 Medicaid of Montana Non Par W Batch TRUE WMCNE1 Medicaid of Nebraska Non Par W Batch TRUE W TRUEMCNV1 Medicaid of Nevada Non Par F Batch TRUE F* TRUECKNH1 Medicaid of New Hampshire Non Par F Batch TRUE TRUECKNJ1 Medicaid of New Jersey Non Par F Batch TRUE FCKNM1 Medicaid of New Mexico Non Par BatchCKNY1 Medicaid of New York Non Par F Batch TRUE WCKNY2 Medicaid of New York (Dental Clinics Only) Non Par F BatchCKNC1 Medicaid of North Carolina Non Par O Batch TRUE OCKND1 Medicaid of North Dakota (ND) Non Par Batch CKOH1 Medicaid of Ohio Non Par Batch TRUE WCKOK1 Medicaid of Oklahoma Non Par Batch TRUE W TRUECKOR1 Medicaid of Oregon Non Par F BatchCKPA1 Medicaid of Pennsylvania (Department of Public Welfare/Medical Assistance) Non Par Batch TRUE FCKRI1 Medicaid of Rhode Island Non Par F BatchCKSC1 Medicaid of South Carolina Non Par BatchTLZ29 Medicaid of South Dakota Par Batch TRUECKTX1 Medicaid of Texas Non Par S BatchCKUT1 Medicaid of Utah Non Par O Batch TRUE OCKVT1 Medicaid of Vermont Non Par F BatchCKVA1 Medicaid of Virginia Non Par BatchCKWA1 Medicaid of Washington Non Par O Batch TRUE OCKWV1 Medicaid of West Virginia Non Par Batch TRUE WCKWI1 Medicaid of Wisconsin Non Par Batch TRUE WCKWY1 Medicaid of Wyoming Non Par F Batch TRUE F TRUEMAHC1 Medical Associate Health Plan (Health Choices) Non Par Batch74323 Medical Benefits Companies Non Par Batch74323 Medical Benefits Mutual (Newark, OH) Non Par BatchTLU03 Medical Mutual of Ohio (MMO) Includes claims submitted under Payer ID CB833. Par BatchTLW15 Mercy Care Non Par Batch33628 Mercy Care RBHA Dental Claims Non Par BatchTLY39 Meritain Health Non Par Batch41124 Meritain Health Minneapolis Non Par Batch23550 Methodist First Choice / Health Plus Peoria Non Par Batch65978 MetLife Par RT TRUE RT Detailed TRUE W TRUEMHP01 Metro Health Plan (Delta Dental of Minnesota Medical Assistance) Non Par Batch

CX083 MGM Resorts International (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUEA1432 Michigan Laborers Health Care Fund Par RT TRUE RT Detailed TRUE S TRUE38238 Michigan Regional Council of Carpenters Employee Benefit Plan / Benesys (MI) Non Par BatchA1404 Michigan State Painters Non Par Batch37281 Mid America Associates Inc Non Par Batch2823 Mid American Benefits Non Par Batch

41101 Midwest Dental Benefits Non Par Batch

MW150 Midwest Operating Engineers Health and Welfare Par Batch TRUE64088 Mississippi Select Healthcare Non Par Batch07275 Missoula County Medical Benefits Plan Non Par Batch

CX083 Molina HealthCare (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUESKYGN Molina Healthcare of Michigan Non Par Batch31415 Momentum Insurance Plans Inc Par BatchTLU78 Morris Associates Non Par Batch36111 Motorola Non Par Batch37233 MPE Employee Benefit Services Non Par BatchMBAAZ Multiflex Dental (Merchants Benefit) Non Par Batch34192 Mutual Health Services (fka Antares Management Solutions) Par BatchCX087 Mutual of Omaha Commercial Non Par BatchTLX30 MVP Health Care Par Batch65085 NAA (North America Administrators LP - Nashville, TN) Non Par Batch34159 NABN Non Par Batch58182 NAPHCARE Inc Non Par BatchTLX23 National Automatic Sprinkler Industry Par Batch TRUE RT Detailed TRUE S TRUE TRUE



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CX045 National Elevator Industry Benefits (NEIB) Non Par Batch

CX057 National Pacific of Texas (NCFLEX)

Includes claims for Pacific Dental Benefits - TX

Previously Submitted Under Payer ID TLW57 Par Batch TRUE S TRUE Must Enroll in EFT First TRUE52120 National Telecommunications Cooperative Association (NTCA/SMC) Par Batch31417 Nationwide Health Plans Non Par Batch19191 Native Care Health, LLC Non Par Batch75191 NCAS - Charlotte Non Par BatchTLX64 NCAS (Harrisburg, PA claims ONLY) Par Batch TRUE RT General TRUE75190 NCAS (Nat'l Claims Admin Services) (Fairfax, VA claims ONLY) Non Par Batch66055 NetCare Life & Health Insurance (NLH) Non Par BatchNDB01 Nevada Dental Benefits Par Batch43351 New England Dental Administrators Par Batch TRUE

66893 New England Financial Non Par BatchNYT01 New York State Teamsters Union Par Batch TRUE RT General TRUETFQ30 Newman Company Non Par Batch69821 Next Level Health Partners Non Par BatchTLX31 NGS CoreSource (fka NGS American) Non Par Batch81264 Nippon Life Insurance Company of America Non Par Batch34159 North American Benefits Network Non Par Batch37314 North Broward Hospital Non Par BatchTLY55 North Carolina Health Choice Non Par O Batch TRUE O61472 North Carolina Health Choice for Children Non Par BatchCX004 North Dakota Dental Service (BCBS ND) Non Par O Batch47570 North Star Administrators Par Batch TRUE RT GeneralTLW42 Northern California Pipe Trades Trust Par Batch TRUE RT Detailed TRUE S TRUE TRUE36347 Northern Illinois Health Plan Non Par BatchTFQ83 Northern Minnesota Dental Non Par Batch88027 Northern Nevada Trust Fund (Reno, NV) Non Par Batch91060 Northwest Administrators Platinum Batch TRUE

93525 Northwest Dental Services Platinum RT TRUE RT General TRUE O

In-State, Credentialed

Providers Only TRUE91136 Northwest Ironworkers Health & Security Fund (F15) Non Par Batch91136 Northwest Roofers & Employers Health & Security Trust Fund (F26) Non Par Batch36346 Northwest Suburban IPA (Illinois) Non Par Batch91136 Northwest Textile Processors and Service Trades (F14) Non Par Batch16644 Nova Healthcare Administrators, Inc (Grand Island, NY) Non Par Batch91136 NW International Association of Machinists (NW IAM) (F39) Non Par Batch91136 NW Plumbers & Pipefitters Health & Welfare Trust (F31) Non Par Batch37299 Nyhart Non Par Batch

GP133 OH / UHC Dental Government Programs

Includes Americhoice Plans Previously Submitted

Under Payer IDs 86047, WT004, WT005, and WT006 Non Par Batch

CX083 Ohana Health Plan (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUEOAC01 Ohio AFSCME Care Plan Non Par Batch65074 Olympus Managed Health Care Non Par BatchOEL12 Operating Engineers Local 12 Non Par Batch

CX083 Ozark Health Plan (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE87068 P5 Health Plan Solutions Non Par BatchCX066 PA Faculty Health & Welfare Non Par Batch70454 PACE CNY a Mediture Payer Non Par Batch86711 PACE Southeast Michigan a Mediture Payer Non Par BatchTLW59 Pacific Dental Benefits - California Par Batch TRUE S TRUE Must Enroll in EFT First TRUETLW58 Pacific Dental Benefits - Nevada Par Batch TRUE S TRUE Must Enroll in EFT First TRUECX056 Pacific Union (CA) Par Batch TRUE S TRUE Must Enroll in EFT First TRUECX060 Pacificare Dental & Vision Plan (DHMO Only) Par Batch TRUE S TRUE Must Enroll in EFT First TRUECX053 Pacificare Dental & Vision Plan (PPO and IND Claims Only) Par Batch TRUE S TRUE Must Enroll in EFT First TRUE93031 PacificSource Administrators Non Par BatchCXPSC PacificSource Community A Performance Health Technology Payer Non Par Batch93029 PacificSource Health Plans Non Par BatchTLY91 Painters Trust Association Par Batch TRUE RT General TRUE

CX083 PALMS Casino Resort (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE04218 Pan American Life Insurance Group Non Par Batch35162 Parkview Health Plan aka Managed Care Services LLC Par Batch23213 Partners Health Plan Non Par Batch25172 PATH Administrators (fka DH Evans Associates Inc) Par Batch10525 Patient Advocates, LLC Non Par Batch32069 Patriot Mutual Insurance Company Non Par Batch TRUE RT Detailed TRUE W TRUE TRUE60054 PDO (Preferred Dental Organization) Par Batch TRUE RT Detailed TRUE W TRUE TRUECKGA3 Peach Care for Kids (GA) Non Par O Batch TRUE O TRUETFQ65 PEHP (Public Employee Health Plan) (UT) Non Par S Batch TRUE S TRUE



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37121 Pequot Pharmaceutical Non Par Batch37121 Pequot Plus Health Benefit Administrators Non Par BatchTLX74 Personal Choice (PA) Platinum RT TRUE RT Detailed TRUE S TRUE95397 Personal Insurance Administrators, Inc. Non Par BatchTLU02 Physicians Care Non Par BatchTLU02 Physicians Care Health Plans Non Par BatchTLU02 Physicians Care Network (MI) Non Par BatchTLZ23 Physicians Health Plan (IN) Non Par BatchCX068 Physician's Mutual - Dental Par Batch TRUE TRUE

CX083 Physicians United Plan-PUP (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE24735 Pinnacle Claims Management Inc (Newport Beach, CA) Non Par BatchPIP01 Pipe Trades Industry Health & Welfare Fund Non Par Batch37287 Planned Administrators, Inc. (PAI) Non Par BatchPCM01 Plasterers' & Cement Masons' Health & Welfare Fund (Local 148) Non Par BatchPLU68 Plumbers & Pipefitters - Local 68 Non Par BatchPCU01 Point Comfort Underwriters Non Par Batch23253 Populytics (fka Spectrum Admin) Par Batch36373 Prairie States Enterprises, Inc. Par Batch31478 Preferred Health Professionals, LLC / Freedom Network Non Par Batch TRUE41147 PreferredOne (MN) Non Par Batch47570 Premera Blue Cross Par Batch TRUE RT GeneralCX078 Premier Access Insurance Par Batch TRUECX029 Premier Dental Plan of Minnesota Non Par BatchPCA01 Primecare Administrators Inc Par BatchPCD01 PrimeCare Dental Plan Par Batch61604 PrimeWest Par Batch TRUE RT General TRUE S TRUE TRUELX049 PrimeWest Health Par Batch TRUE RT General TRUE S TRUE TRUE61271 Principal Financial Group Par Batch TRUE61271 Principal Mutual Life Insurance Co. Par Batch TRUE38217 Priority Health Non Par Batch36331 Professional Benefit Administrators, Inc. (Oak Brook, IL) Non Par Batch88029 Prominence Health Plan (Saint Mary's Health Plan) Non Par Batch

68195 Provident Life & Accident Insurance Company of America Par Batch TRUE S


enrolled in EFT.60054 Prudential for Health Par Batch TRUE RT Detailed TRUE W TRUE TRUE60054 Prudential HealthCare & Life Ins. Co of America Par Batch TRUE RT Detailed TRUE W TRUE TRUE60054 Prudential HealthCare Health Maintenance Organization Par Batch TRUE RT Detailed TRUE W TRUE TRUE60054 Prudential HealthCare HMO for Small Business Par Batch TRUE RT Detailed TRUE W TRUE TRUE60054 Prudential Healthcare of America Inc. Par Batch TRUE RT Detailed TRUE W TRUE TRUE60054 Prudential HealthCare POS for Small Business Par Batch TRUE RT Detailed TRUE W TRUE TRUE60054 Prudential HealthCare PPO for Small Business Par Batch TRUE RT Detailed TRUE W TRUE TRUE91136 Puget Sound Electrical Workers Healthcare Trust (PSEW) (F33) Non Par BatchCX077 Quality Plan Administrators Inc. Non Par Batch91176 RBMS (Risk and Benefit Management Services) Non Par Batch

TLU43 Regence BCBS - Utah

Includes Claims for Regence Blue Cross UT

Previously Submitted Under Payer ID TLU95 Non Par Batch TRUETFQ77 Regence BCBS - Utah (Federal Only) Non Par Batch TRUECB850 Regence BlueCross BlueShield of Oregon Non Par Batch TRUE93200 Regence BlueCross BlueShield of Washington Non Par Batch TRUECBID2 Regence BlueShield of Idaho Non Par Batch TRUETLU30 Regence Life and Health / LifeMap Non Par Batch38221 Regency Employee Benefits Non Par Batch47076 Regional Care, Inc. (NE) Non Par Batch36088 Reliance Standard Life Par Batch TRUE TRUE80314 ReliaStar (CA) Non Par Batch TRUE O TRUERLHA1 Renaissance Life and Health Par RT TRUE S TRUE50664 Riverside San Bernardino County Indian Health Inc. Non Par Batch41625 Rochester Public Schools Non Par Batch

CX083 Rocky Mountain Hospital & Medical Service - OSB High & High (Admin by Liberty Dental)


Submitted Under TPC12 Par Batch TRUE84102 Rocky Mountain Life Dental Non Par BatchRR001 Royal Resources Non Par BatchTFQ97 S & S HealthCare Strategies Non Par BatchCX030 Safeguard Dental & Vision Non Par BatchCX048 Safeguard DHMO Non Par Batch37105 Sage Technologies / Cannon Cochran Mgmt Services Inc (IL Plan Only) Non Par BatchTFQ67 Samba Federal Employee Benefit Assoc Non Par Batch96400 San Diego PACE a Mediture Payer Non Par Batch

CX083 Sands Bethworks Gaming (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE91184 Sanford Health Plan Non Par BatchTPC05 Sanford Health Plan of MN Non Par Batch



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37288 Santa Barbara Cottage Hospital Non Par Batch

CX083 Santa Clara Family Health Plan (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUESDCOM Scion Commercial Non Par BatchSCION Scion Dental Non Par Batch86057 Secure Care Dental Par BatchTLY64 Secure Health Plan of GA Non Par Batch93742 Securian Dental Plan Non Par Batch TRUE RT Detailed TRUE W TRUE TRUE35202 Security Administrative Services Non Par Batch39045 Security Health Plan Non Par BatchTLX77 Security Life Insurance Company of America Par Batch TRUE TRUE64088 Select Administrative Services Non Par BatchTFQ49 Select Benefit Administrators (IA) Non Par BatchTPC17 Select Health Non Par Batch TRUE S TRUECX109 Sele-Dent Non Par Batch34131 Self Funded Plans Inc. Non Par BatchTLX16 Self Insured Plans (FL) Non Par Batch36426 Sendero Health Plans Non Par Batch39033 Sentry Life Insurance Company Non Par BatchTLW25 Shasta Administrative Services Non Par BatchSMW01 Sheet Metal Workers Health & Welfare Fund - Local 91 Non Par Batch30920 Sheet Metal Workers Local 20 Par Batch TRUE RT General TRUE

76342 Sierra Health Services

Includes Claims for Health Plan of Nevada Previously

Submitted Under Payer ID TLY56 Non Par BatchCX046 Sifnifca Benefit Services Inc Par BatchTLY60 SIHO Par Batch84076 Sinclair Health Plan Non Par BatchCX020 SISCO (Self Insured Services Company) Non Par Batch76578 Solstice Benefits Inc Par BatchTPC11 South Carolina Healthy Connections Non Par Batch23266 South Central Preferred PPO (York, PA) (IHS Gateway Payer) Non Par Batch35227 South Point Hotel & Casino Non Par BatchSEI01 Southeastern Service Employee International Union (SEIU) Non Par Batch26374 Southland Benefits Solutions Non Par BatchCX100 Southwest Service Administrators Non Par Batch60054 Southwestern Bell Par Batch TRUE RT Detailed TRUE W TRUE TRUE60054 Southwestern Bell Exec. - Custom Care Par Batch TRUE RT Detailed TRUE W TRUE TRUE60054 Southwestern Bell Exec. - Southwestern Bell Par Batch TRUE RT Detailed TRUE W TRUE TRUE84147 Spina Bifida - VA HAC Non Par BatchDSCO1 Spraying System Co Non Par Batch69019 Standard Insurance Company (OR) Par Batch TRUE TRUE89009 Standard Insurance Company of New York Par Batch TRUE TRUECCPSP STAR + Plus Value Added Non Par BatchCCPSH STAR Health / Delta Dental - CA (Star) Non Par BatchSTR01 Starmount Life Insurance Company Non Par Batch68381 Student Insurance - Boston Mutual Life Insurance Company Non Par Batch68381 Student Insurance - Mega Life & Health Insurance Company Non Par Batch68381 Student Insurance - Mid-West National Life Ins Co of Tenn Non Par Batch68381 Student Insurance - Reliance Insurance Company Non Par Batch95202 SummaCare Non Par Batch TRUE W TRUE37301 Summit America Insurance Non Par Batch67814 Sun Life & Health Insurance Non Par Batch70408 Sun Life Financial fka Assurant Employee Benefits Par Batch TRUE31117 Superior Dental Care Par BatchCPPSW SuperiorSTAR Pregnant Women Non Par Batch88067 Tall Tree Administrators Non Par Batch12116 Tennessee Valley Healthcare System (Veterans Affairs) Non Par BatchCPPTX Texas CHIP Dental Services Par Batch TRUE RT Detailed TRUE S TRUE TRUE74227 The Chesapeake Life Insurance Company - Student Insurance Non Par Batch73288 The Dental Companies Non Par Batch73288 The Dental Concern Non Par BatchTDN01 The Dental Network of Maryland (in state dentists only) Non Par Batch TRUE RT Detailed TRUE S TRUE TRUETDN02 The Dental Network of Maryland (out of state dentists -- not located in MD or DC) Non Par Batch TRUE RT Detailed TRUE S TRUE TRUE34150 The Health Plan (fka Health Plan Upper Ohio Valley) Non Par BatchCRIHB The Humboldt-DelNorte Non Par BatchTLW10 The Loomis Company Non Par BatchA1402 TIC International Inc aka Millrights Non Par BatchTIC01 TIC International, Inc. Non Par BatchTLY35 Total Dental Administrators (AZ) Par Batch TRUETLY36 Total Dental Administrators (UT) Par Batch TRUETLY34 TR Paul, Inc. Non Par Batch65978 Travelers (now MetLife) Par RT TRUE RT Detailed TRUE W TRUECX002 Tricare Dental Plan (UCCI) Platinum RT TRUE RT Detailed TRUE S TRUE



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CDCA1 Tricare Retiree Dental Par Batch TRUE RT Detailed TRUE S

CHSWT Tri-Counties Welfare Trust Fund


Administrators Non Par Batch84103 Trigon Blue Cross and Blue Shield Non Par Batch TRUE O TRUE31144 TriState Benefit Solutions Non Par BatchILDTA TruAssure Insurance Co Par Batch TRUE91078 Trusteed Plans Service Corporation (Tacoma, WA) Non Par Batch61425 Trustmark aka ACEC Health Plan Non Par BatchTFQ75 UCHealth Plan Administrators Par BatchUFC02 UFCW - Local 880 Non Par Batch27401 UFCW - MI Non Par BatchWT073 UFCW Local 711 Par BatchUFC01 UFCW of Central Ohio Par RT TRUE RT Detailed TRUE S TRUE41206 UltraBenefits Inc Non Par Batch75196 UMR - Harrington (fka Harrington Benefit Services Westerville) Non Par Batch95266 UMR - Harrington (fka Harrington Benefit Services) Non Par Batch37237 UMR - Lexington (fka Lexington Commonwealth -ASGI) Non Par Batch74223 UMR - San Antonio (fka Benefit Planners / UICI Administrators - State of Nevada) Non Par Batch39026 UMR - Wausau fka Fiserv / Wausau Benefits Non Par Batch79480 UMR (fka Midwest Security Administrators) Non Par Batch TRUE52180 UMWA Health and Retirement Funds Non Par Batch80314 UNICARE Non Par Batch TRUE O TRUETLA03 Unified Group Services Non Par Batch75243 Uniform Medical Plan / Harrington Benefit / Centra Benefit Services Non Par BatchTLY58 United Administrative Services Inc Non Par Batch20090 United Claim Solutions Non Par BatchCX013 United Concordia - Dental Plus Platinum RT TRUE RT Detailed TRUE S TRUECX007 United Concordia - Fee for Service Platinum RT TRUE RT Detailed TRUE S TRUE52133 United Healthcare -- Dental Par Batch TRUE RT General TRUE S TRUE Must Enroll in EFT First TRUE33108 United Medical Resources - Cincinnati Non Par Batch TRUE13545 United States Life Insurance Company of New Jersey (Neptune NJ) Non Par Batch66705 Unity Health Insurance Corp. Non Par Batch16105 Univera of New York Platinum RT TRUE RT General TRUESX155 University of Utah Health Plans Non Par BatchWT017 Unum Dental Plan Platinum RT TRUE RT Detailed TRUE S TRUE23281 UPMC Health Plan Par Batch TRUE S37324 Upper Peninsula Health Group (TPA) Non Par BatchTLW48 US Benefits (OR) Non Par BatchCX110 UT Chips Non Par Batch64009 Valir PACE a Mediture Payer Non Par Batch60054 Varian Health Care Plan Par Batch TRUE RT Detailed TRUE W TRUE TRUE72187 Varipro Non Par Batch

CX083 Venetian (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE48123 Via Christi HOPE a Mediture Payer Non Par Batch59266 Volusia Health Network Non Par Batch91136 Washington State Council of County & City Employees (WSCCCE) (F36) Non Par Batch73155 Waterstone Benefit Administrators Non Par Batch59332 Web TPA Inc of TX Non Par Batch75261 webTPA / Community Health Electronic Claims / CHEC Non Par Batch

CX083 Welborn Health Plans


Submitted Under TPC12 Par Batch TRUE91136 Welfare & Pension Administration Service Inc Non Par Batch

CX083 Wellcare (Admin by LIBERTY Dental Plan)



CX083 WellPoint (Admin by LIBERTY Dental Plan)


Submitted Under TPC12 Par Batch TRUE87825 Wells Fargo TPA Non Par BatchTLY66 Wells Fargo TPA (GA) (fka JSL Administrators) Non Par BatchTLY65 Wells Fargo TPA (NC) (fka JSL Administrators) Non Par Batch93128 Western Grocers Employee Benefit Trust Par Batch24735 Western Grower's Assurance Trust (Newport Beach, CA) Non Par BatchTLW33 Western PA Teamsters Fund Platinum RT TRUE RT Detailed TRUE S TRUE91060 Western Teamsters Welfare Trust Platinum Batch TRUEWIMAN WI Medicare Advantage Network Par Batch TRUE RT Detailed TRUE S TRUE93050 William C Earhart Co Inc Non Par BatchR7002 Wilson McShane Corp Non Par Batch TRUE RT Detailed TRUE S TRUETLX68 Worksite Benefit Services, LLC Non Par BatchCXWVC WVCH Capitol Dental A Performance Health Technology Payer Non Par BatchTLY21 Zenith Administrators (MN) Non Par Batch TRUE RT Detailed TRUE S TRUE



14 of 16

Tesia Clearinghouse

www.Tesia.com



Tel: (800) 724-7240


eAttachments


Enrollment

Required Type

270s

Available

Enrollment

Required Type

Level of


835s

Available

Enrollment

Required

Paper EOBs

Shutoff

when

Enrolled ERA Notes

Accepts Tesia

eAttachments


TLY27 Zenith American Solutions

Includes Administrative Services Claims Previously

Submitted Under Payer IDs TLU87 and WT072 and

Zenith Administrator (non-MN) Claims Previously

Submitted Under TLY** Par Batch TRUE RT General TRUE



15 of 16

Enrollment Type Definitions

STesia Clearinghouse is able to facilitate enrollment with the payer. The provider requests enrollment by completing a Tesia Enrollment Request Form and supplying

the requested demographic information - including Tax ID and NPIs.

OThe payer requires that the provider designate Tesia Clearinghouse as their Billing Agent / Clearinghouse via their on-line web portal. The provider must notify Tesia

Clearinghouse once the process is completed.

WThe payer requires the submission of their enrollment paperwork. Tesia Clearinghouse will supply the provider with a copy of the paperwork which can be faxed,

emailed, or mailed back to us for submission to the payer.

FThe payer requires the submission of an original copy of their enrollment paperwork. Tesia Clearinghouse will supply the provider with a copy of the paperwork

which must be mailed back to us for submission to the payer.

ITesia Clearinghouse is able to initiate the enrollment process with the payer; however, the provider must work directly with the payer in order to complete

enrollment. The provider must notify Tesia Clearinghouse once the process is completed.

* Indicates that the paperwork required is the same form used for 837D enrollment.

L Indicates that the provider must also submit a letter of authorization on their office letterhead.

Documents

Payer Identification Information Claims Processing Eligibility ...and be sure to submit all required fields, including Payor Name and Complete Address. (C) 2014 Tesia Clearinghouse