IDAHO BLUE CROSS BLUE SHIELD

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					             LOUISIANA BLUE CROSS BLUE SHIELD
       ELECTRONIC CLAIMS ENROLLMENT REGISTRATION
____________________________________________________________
Payer ID Number                         23739

Electronic Registrations                PLEASE COMPLETE
                                        Page 2 – Blue Cross
                                            Group Provider Number– (if applicable) must be entered on the line
                                               labeled “Group Number.” DO NOT call Patterson Technology Center for
                                               this provider number. Due to confidentiality reasons, Patterson
                                               Technology Center cannot obtain this number Either contact Blue Cross
                                               Blue Shield Louisiana or check your EOB’s or Remittance Advice for
                                               your provider number
                                            Rendering Provider Number – must be entered on line labeled
                                               “Rendering Number.” DO NOT call Patterson Technology Center for this
                                               provider number. Due to confidentiality reasons, Patterson Technology
                                               Center cannot obtain this number. Either contact Blue Cross Blue Shield
                                               Louisiana or check your EOB’s or Remittance Advice for your provider
                                               number.
                                            Date – must be entered on line labeled “Date”

Send Original Enrollment Forms to:      WebMD Dental
                                        Attn: Provider Registration
                                        220 Burnham Street
                                        South Windsor, CT 06074
                                                Or
                                        Fax:    (860) 289-0055

                                        *DO NOT MAIL THIS FORM TO LOUISIANA BLUE CROSS BLUE SHIELD.
                                        *Keep this cover sheet and a copy of the completed form.

Enrollment Confirmation                 Enrollment will be coordinated between WebMD Dental and BCBS LA. When
                                        WebMD Dental receives your approval status from BCBS, WebMD Dental will
                                        notify Patterson Technology Center and Patterson Technology Center will
                                        contact your office.

Special Notes                           If the provider does not have an alpha numeric Louisiana Blue Cross Blue Shield
                                        provider ID the provider must contact Louisiana Blue Cross Blue Shield to obtain
                                        one.

Changing Electronic Billing Agents: If a provider currently submits claims through a different billing agent other than
                                    WebMD Dental each provider must re-enroll following the procedures listed
                                    above.

Contact Phone Numbers                   BCBS LA                                 (225) 291-4334
                                        WebMD Dental Provider Enrollment        (888) 255-7293

				
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