South Carolina · March 9, 2015 2 Carrier / Payer Codes assigned for South Carolina Definitions:...

March 9, 2015

Carrier/Payer Codes

assigned for

South Carolina

March 9, 2015 2

Carrier / Payer Codes assigned for South Carolina Definitions:

Open = Code is available for re-assignment

Dormant = Code is in suspension for one year to allow any outstanding claims to process. These codes identified payers that had little or no activity and

were eliminated.

Inactive = Code is in suspension until research is complete.

Column II of Payer Codes indicates line of business (where known):

DEN = Dental only

FFS = Fee for Service

HCK = Healthy Connection Kids

HMO = Managed Care

MA = Medicare Advantage

MMC = Medicaid Managed Care

PPA = Preferred Purchasing Alliance; serves as a purchasing agent for members. Employers join together in order to obtain health insurance rates.

POS = Plan which require enrollment by beneficiaries and often use primary care physicians as “gate keepers,” but are open and allow enrollees to

refer themselves outside the network for care, albeit at increased cost sharing.

PPO = Managed care plan with incentives to use “preferred” providers. Plans have responsibility for claims processing & payment; e.g. PHP

PFFS = Private Fee for Service

REP = Repricer; e.g. MedCost

RPPO = Regional PPO

RX = Prescription claims only

SI = Self Insured

SNP = Special Needs Plan

TPA = Third Party Administrator

MS = Medicare Supplement

Payer codes of large companies list the home office address, therefore you should use the address on the patient’s identification card when submitting claims.

Medicaid requires use of the assigned 3-digit code appearing on the patient’s Medicaid ID card in FL 50 of the UB-92. Medicaid uses the code in conjunction with the policy number

to establish a primary coverage record that will notify all providers of that patient’s coverage. If the correct payer code is not used on Medicaid claims, the claim may reject.

REQUESTS FOR CODE ASSIGNMENT SHOULD BE SENT TO SCHA; ATTN: CARMEN GOULET ([email protected])

REQUESTS MUST CONTAIN THE NAME, ADDRESS AND PHONE NUMBER OF THE PAYER AND THE LINE OF BUSINESS, E.G. HMO, PPO, FFS, ETC. SINCE HMOS AND PPOS

ARE ASSIGNED A SEPARATE CODE FROM THE REGULAR LINE OF COVERAGE.

mailto:[email protected]

March 9, 2015

SPONSOR CODE LISTING:

400 BCBS State Employees Health Plan C63 BCBS of South Carolina: Medicare Blue & Medicare Blue

Plus

406 Companion Information Management Resources

401 Blue Cross/Blue Shield of S.C. C62 BCBS of South Carolina: Medicare Blue Private 416 Companion Benefit s

922 BlueChoice Healthplan of S.C.(HMO) C64 Blue Choice Health Plan: Platinum Advantage 433 Companion Life Insurance

402 FEP Blue Cross

606-649 AGENCIES AND CHARITABLE ORGANIZATIONS

600 Self-Pay 617 Medicare Railroad (PGBA) (Prof. - Part B) 634 DHEC Cancer Screening

601 Hill Burton (Category A) 618 Medicare Part A (BCBS) 635 Medicare Part A Mutual of Omaha

602 Hill Burton (Category B) 619 Medicaid, S.C. 636 Medicare Part B Mutual of Omaha

603 Other Indigent (Hospital Charity) 620 Medicare Part B Only (BCBS) 637 First Choice by Select Health - Medicaid HMO

604 CHAMPVA 621 Department of Corrections 638 United Healthcare Community Plan (formerly Unison

Health Plan)

605 Medically Indigent Assistance Program 622 Workmen's Compensation 639 HealthFirst - Medicaid HMO

606 Vocational Rehab. General 623 Carolina Medicare Prime(HMO) 640 TrailBlazer § 1011: Undocumented Alien Program

607 WPS TRICARE for Life 624 Other Sponsor 641 CHAMPVA for Life

608 Vocational Rehab. Disability 625 DHEC Migrant Health 642 TRICARE for Life

609 Commission for the Blind 626 DHEC Sickle Cell 643 Medicare/Medicaid - BCBS of Tennessee

610 DHEC Cancer Diagnosis 627 DHEC Heart 644 Medicare/Medicaid - BCBS of Georgia

611 DHEC Crippled Children 628 DHEC Hemophilia 645 Medicaid Out-of-State Managed Care

612 DHEC Low Risk Maternity 629 DHEC Family Planning 646 Medicare CIGNA

613 DHEC High Risk Maternity 630 DHEC TB 647 Crime Victims Other than Sexual/Physical Abuse

614 TRICARE 631 Shriners 649 Medicaid North Carolina

615 DHEC Sterilization 632 Crime Victims (Sexual/Physical Abuse) CAS Medicaid Casualty Claims

616 Medicaid Out-of-State 633 Veterans Administration

650-699 COUNTY SPONSORS

650 Abbeville 662 Chesterfield 674 Hampton 685 Newberry 696 Out-of-State GA

651 Aiken 663 Clarendon 675 Horry 686 Oconee 697 Out-of-State NC

652 Allendale 664 Colleton 676 Jasper 687 Orangeburg 698 Out-of-State OTHER

653 Anderson 665 Darlington 677 Kershaw 688 Pickens 699 Out-of-State VA

654 Bamberg 666 Dillon 678 Lancaster 689 Richland

655 Barnwell 667 Dorchester 679 Laurens 690 Saluda

656 Beaufort 668 Edgefield 680 Lee 691 Spartanburg

657 Berkeley 669 Fairfield 681 Lexington 692 Sumter

658 Calhoun 670 Florence 682 Marion 693 Union

659 Charleston 671 Georgetown 683 Marlboro 694 Williamsburg

660 Cherokee 672 Greenville 684 McCormick 695 York

661 Chester 673 Greenwood

March 9, 2015 4

SC

CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF

CHANGE

NOTE

100 FFS Aetna US Healthcare PO Drawer A.1

Greensboro, NC 27410

910.854.2050 60054 see also #899, #917

101 PPO International Claims Services 27092 Burbank St

Foothill Ranch, CA 92610

877.916.7920 N/A N/A 07.02.08

102 FFS Federal Insurance (other)

103 PPO United Claims Solutions 10835 N. 25th Ave, Ste 105

Phoenix AZ 85029

866.744.8482 N/A N/A 07.08.08 Repricer

104 HMO Kaiser Foundation Health Plan of Southern

California

PO Box 7004

Downey CA 90242

800-390-3510 N/A 94134 07/18/08 Traditional HMO

105 FFS Liberty Life Insurance Co. PO Box 19038

Greenville, SC 29602

864.609.8366 61492

106 FFS American Fidelity Assurance Benefits PO Box 25160

Oklahoma City, OK 73125.0160

800.662.1113

405.523.5025

60410

107 FFS Mutual of Omaha-Group Policy Mutual of Omaha Plaza

Omaha, NE 68175

800.228.3338

402.342.7600

71412 aka United of Omaha.Individual Policy

108 Metropolitan Life PO Box 3015

Utica, NY 13504

800.638.6626 65978

109 FFS Jefferson Pilot Insurance Co. PO Box 26011


919.691.3918

919.691.3000

67865 Group Claims

110 HMO AmeriHealth HMO, Inc PO Box 41574

Philadelphia PA 19101-1574

866-681-7373 N/A 23037 07/18/08 Old NEIC code 95044 changed 10/2/08

111 FFS Prudential Insurance Co. of America PO Box 2229

Jacksonville, FL 32231.0077

904.391.4991 68241 see #882(HMO)

112 TPA United Healthcare Student Resources PO Box 809025

Dallas TX 75380.9025

800.767.0700

74227 12.11.07 Sickness/Illness Policy

1 yr. blanket coverage

113 FFS United Healthcare Corp. PO Box 1459

Minneapolis, MN 55440

612.936.1300 87726 also see: #715, #881, #947, #950

114 PPO ClaimEDIx Inc

PO Box 140067

Kansa City, MO 64114

800.922.4362 N/A 74048 07/21/08 Repricer

www.claimedix.com

115 FFS Allstate Insurance PO Box 2874

Clinton IA 52733

800.255.7828 Address updated 10/13/14

116 FFS Willis Corroon Administrative Services PO Box 305154

Nashville, TN 37230.5154

800.255.8109

117 TPA Hewitt Coleman & Assoc. PO Box 3808


118 FFS American Health & Life Insurance 714 Main Street

Fort Worth, TX 76102

800.433.7090

817.390.8000

60518

119 FFS American Heritage Life Insurance 1776 American Heritage

Jacksonville, FL 32224

904.992.1776 60534

120 FFS American National Insurance PO Box 1790

Galveston, TX 77553

800.899.6803 60739 74048

121 Greater Health Services, Inc. PO Box 3480

Monroe, NC 28111

704.225.8887

March 9, 2015 5

SC


CHANGE

NOTE

122 FFS Atlantic Coast Life Insurance Co. PO Box 71729

Charleston, SC 29415

803.746.1400 61115 Attn: Claims Department

123 FFS Bankers Life & Casualty Co. PO Box 66927

Chicago, IL 60666.0927

800.621.3724

800.777.7000

31263

124 FFS United Commercial Travelers of America PO Box 159019

Columbus, OH 43215

800.848.0123

125 FFS American Travelers Life Insurance 3220 Tillman Drive

Ben Salem, PA 19020

800.441.3978

215.244.1600

126 PPO

NETWK

Health Plan Services (Coventry Health Care ) PO Box 24146

Seattle WA 98124

800.861.0056 59140 7/24/08 First Health Life & Health subsidiary of

Coventy Health Care www.fh-hps.com

127 BenefitSource, Inc. PO Box 240

Monroe MI 48161

800.423.1028 38257 04.11.08 www.benefitsource.com

128 Capitol Life Insurance Co. PO Box 1200

Denver, CO 80201

800.525.2115

303.273.9303

129 PPO Intergroup Services Corporation 101 Lindenwood Dr., Ste 150

Malvern PA 19355

800-537-9389 23287 8/26/08 www.igs-ppo.com

130 FFS Employers Life Insurance Corp. PO Box 5787

Spartanburg, SC 29304

888.962.8437 77356 37249 was Employers Life Ins. Co. of Wausau (BSBS)

Uses Preferrd Blue network

131 FFS USI Administrators PO Box 9888

Savannah, GA 31412

912.691.1551 USI bought Jones, Hill & Mercer Insurance

132 FFS Colonial Life & Accident Insurance PO Box 1365

Columbia, SC 29202

800.325.2467

803.798.7000

62049

133 FFS Combined Insurance Co. of America 5050 N. Broadway

Chicago, IL 60640

312.769.8942 62146

134 FFS CIGNA –Connecticut General Life Insurance PO Box 18802

Chattanooga, TN 37422

800.842.8953 62308

135 Allied Group Insurance Trust 111 W. 10th Street

Kansas City, MO 64105

136 POS CIGNA Flexcare PO Box 30575

Charlotte, NC 28230.0575

800.632.3211

137 Educators Mutual Life Insurance Co. PO Box 3149

Lancaster, PA 17601

717.397.2751

138 TPA Coresource PO Box 2920

Clinton IA 52733-2920

800.624.7130 35182 8/26/08 www.coresource.com

139 TPA Wausau Benefits, Inc. POB 8013

Wausau, WI 54402

800.826.9781

140 MA

PFFS

Sterling Option I, II, III and IV PO Box 5348

Bellingham, WA 98227.5348

800.688.0010 91151 Use this information for all 4 Options.

(Changes/Additions 1.3.8)

141 SI NEOA Health Benefits Fund PO Box 3070

Knoxville, TN 37927

Adm. Systems of Tennessee

142 SC Dept of Disabilities and Special Needs PO Box 4706

Columbia SC 29240

803.898.9795 02.15.08 Attn: Lisa Weeks

Pilot Program

143 TPA UMR

PO Box 30530

Salt Lake City UT 84130

800-466-8182 95266 9/3/08 www.umr.com

http://www.fh-hps.com/

http://www.coresource.com/

March 9, 2015 6

SC


CHANGE

NOTE

144 FFS Globe Life & Accident Insurance Globe Life Ctr, 204 N. Robinson

St.

Oklahoma City, OK 73184

800.654.5433

405.270.1400

91472

145 FFS GMP Employers Retiree Trust 5245 Big Pine Way SE

Fort Myers, FL 33907

941.936.6242

146 FFS Hartford Insurance Co. PO Box 2999

Hartford, CT 06104

860.843.8744 Individual Claims Only

147 FFS State Mutual Insurance Co. PO Box 10811

Clearwater, FL 33757.8811

877.872.5500

148 FFS Monumental Life Insurance Co.

Is TransAmerica Life

PO Box 61

Durham, NC 27702

800.444.5431 66281 Both companies are members of the

Aegon Group and are one and the

same

Address change 8/5/14

149 FFS Insurance Company of North America (INA) 195 Broadway 1lth Floor

New York, NY 10007.3100

212.618.4000

150 FFS American General Life & Accident Insurance

Co.

American General Center

Nashville, TN 37250

800.888.2452

1

66672 62030

151 MMC Carelink – Medicaid PO Box 7373

London KY 40742

800.348.2922 25140 09/03/08

152 HMO MEDICA PO Box 30990


800.458.5512 94265 9.08.08 www.medica.com

153 FFS Kanawha Life Insurance PO Box 1000

Lancaster, SC 29721

800.635.4252

803.283.5300

57038

154 PPO Consumer Driven Benefits Association

(CDBA)

PO Box 6080-228

Mission Viejo CA 92690-6080

888.411.4208 N/A 09/08/08 Provider Network Program: First Access

155 CrossAmerica Health Plan PO Box 5778

Parsippany NJ 07054

866.302.7332 23212

10/2/08

01.02.08 Limited Indemnity plan. (Paper claims only)

Crossamericausa.com

156 FFS Life Insurance Co. of Georgia PO Box 105006

Atlanta, GA 30348 5006

404.980.5100 65471

157 FFS Life Insurance Co. of Virginia PO Box 27601

Richmond, VA 23230

804.281.6000

158 FFS Lincoln National Life Insurance Co. PO Box 1110

Fort Wayne, IN 46801

800.454.6265

219.455.2000

65676 73288

159 Maksin Management Corp CN 98000

Pennsauken, NJ 08110

800.257.6250

160 FFS UniCare Life & Health Insurance Co. 1359 Main Street

Springfield, MA 01103 1630

800.288.8630 65935 was Mass. Mutual Life Ins.

161 MS AMA Insurance Agency, Inc

Medicare Supplement Claim Unit

200 North LaSalle Street, Suite

400, Chicago, IL 60681 9785

800.458.5736 TH071

162 FFS Harvard Pilgrim Healthcare (aka First

Seniority Freedom)

PO Box 656653

San Antonio Tx 8265-6653

800.421.3550 87726 9-17-08

163 FFS Nationwide Life Insurance Co. 1 Nationwide Plaza

Columbus, OH 43216

800.535.8600

614.249.7111

66869 31417

164 Dormant 6.08 Was American Progressive Insurance

http://www.medica.com/

March 9, 2015 7

SC


CHANGE

NOTE

165 FFS New York Life Insurance Co. PO Box 105095

Atlanta, GA 30348

800.388.4580 66915 Group Claims Only

166 Dormant 4/07 was Capitol American Life Insurance Co.

167 PPO American International Group (AIG)

Accident & Health

PO Box 3726

Seattle WA 98124

877.503.9095 59140 9/30/08

168 FFS Precise Benefit Administrators PO Box 9064

Jericho, NY 11753

516.390.6000

169 SI Crown Cork & Seal Co., Inc. 930 Beaumont Avenue


803.585.6456

170 FFS Occidental Life Insurance Co. of North

Carolina

PO Box 10324

Raleigh, NC 27605

800.334.4324

919.831.8189

67148

171 TPA AON Consulting PO Box 66

Winston Salem, NC 27102

800.368.3804

910.725.0040

172 FFS Paul Revere Insurance Group 18 Chestnut St.

Worchester, MA 01608

508.799.4441

173 FFS Pennsylvania Life Insurance Co. 3130 Wilshire Blvd.

Santa Monica, CA 90406

213.828.6411

174 SI National Maritime Union (NMU) Pension &

Welfare Fund

PO Box 9765

Scottsdale, AZ 85252

800.252.4674 Coventry Health Care

175 FFS Columbia Universal Life Insurance Co. PO Box Sept. 200225

Austin, TX 78720.0225

800.880.1370

512.345.3200

77720 aka Hill Country Life

176 FFS Guidestar Health Systems PO Box 830626

Birmingham, AL 35238.5012

205.879.9230 was Protective Life

177 Cinergy Health Preferred Plan 144 N Beverwyck Rd #332

Lake Hiawatha NJ 07034-1997

800.847.1148 23212 9/30/08 Limited medical benefit plan

178 Insurance & Benefit Advocate, Inc 5838 W Brick Rd Suite 106

South Bend IN 46628

866.200.6700 11.30.07 Secondary Ins. Only

179 FFS Deseret Mutual Insurance Co. PO Box 45530

Salt Lake City, UT 84145

800.777.3622

801.578.5600

81019

180 ESIS PO Box 31122

Tampa FL 33631

800.830.6823

800.884.7975

11.08.07 Attn.: Carol Poe

181 TPA Group Administrators, Ltd. 1880 N. Roselle Rd, Ste. 214

Schaumberg, IL 60195

800.323.1683

708.519.1880

36338

182 Penn Treaty Network America Ins. Company PO Box 7066

Allentown PA 18105.7066

800.362.0700

10.30.07 610.965.6962.(Claims may be faxed)

Long Term Care

183 Gilsbar, Inc. PO Box 998

Covington, LA 70434

800.234.2643

184 Dormant 8/06

185 S&S Healthcare Strategies PO Box 16511

Cincinnati, OH 45216

800.717.2872

186 FFS Southland Life Insurance Co. PO Box 105006

Atlanta, GA 30348.5006

404.980.5100

March 9, 2015 8

SC


CHANGE

NOTE

187 FFS Reliance Standard Life Insurance

RSL Specialty Products Administration (TPA)

PO Box 82510, Lincoln, NE

68501

509 S. Lenola Rd, #2,

Moorestown, NJ 08057

800.497.7044

866.375.0775

NEIC.ASRMI

188 FFS Standard Life & Casualty Insurance PO Box 1514

Fort Mill, SC 29716

800.227.0251

803.548.3657

189 International Educational Exchange Services PO Box 370

Ithaca NY 14851-0370

866-433-7462 16158 10/22/08 Underwritten by BSC Insurance Co. (BCSI)

www.iees.com

190 SI Boilermakers National H&W Fund 754 Minnesota Ave, Ste. 522

Kansas City, KS 66101.2762

913.342.6555 36609

191 HMO Coventry Healthcare of Delaware, Inc. PO Box 7713

London KY 40742

800.833.7423

25130 10.23.07

192 COA Coventry of Nebraska, Inc. PO Box 7705

London KY 40742

800.288.3343

25136 10.23.07 Multiple plan types, all use same NEIC

193 Allstate Workplace Division

Attn: Group Claims Department

PO Box 853916

Richardson, TX 75085.3916

800.937.7039

194 DAKOTACARE 1323 S. Minnesota Avenue

Sioux Falls, SD 57105

800.325.5598

195 Union Bankers Insurance Co. 500 N. Akard St.

Dallas, TX 75201

800.824.3577

196 United Benefit Life Insurance 3909 Hulen St., #300


800.732.0655

197 Harvard Pilgrim Health Care PO Box 699183

Quincy, MA 02269.9183

888.888.4742 04271

198 Universal Fidelity Life Ins. Co. PO Box 1428

Duncan, OK 735344

800.366.835 78003

199 All Other

200 All American Life Insurance Co. O’Hara Plaza, 8501 W. Higgins

Rd.

Chicago, IL 60631

312.399.6500

201 HCH Administrators (Healthcare Horizons) PO Box 1986

Peoria, IL 61656

800.322.1516 37111

202 John Hancock Insurance Company

Long Term Care Benefit Center B5.03

PO Box 852

Boston MA 02117

800.233.1449 10.30.07 Long Term Care

203 PPO Health Care Support/Private Health Care

System (PHCS)

29 Columbia Heights

Brooklyn NY 11201

800.554.4022 10/27/08 PHCS has been acquired by Multiplan

www.phcs.com

204 Self Insured Benefit Administrators 18167 US Hwy. 19 N

Clearwater, FL 33764

727.532.0400 59111

205 Fidelity Security Life Insurance Co. 3130 Broadway

Kansas City, MO 64111.2406

800 648.8624

206 REP MedCost Benefits Services PO Box 25987

Winston.Salem, NC 27114.5687

800.795.1023 56162

207 Medical Savings Health Plan 419 E. Main St.

Middleton, NY 10940

317.329.8222

208 SIEBA, LTD PO Box 5000

Endicott, NY 13761

800.893.0777

http://www.iees.com/

March 9, 2015 9

SC


CHANGE

NOTE

209 Summit America Insurance Services 7400 College Blvd. Ste. 100

Overland Park KS 66210

877.246.6997 37301 04.07.08 Student Risk Specialty Insurance

210 Ameritas Bank Assurance PO Box 82520

Lincoln, NE 68501

800.255.9678

211 TPA Coordinated Benefit Plans Inc (CBPI) PO Box 853925

Richardson TX 75085-3925

800.753.1000 95377 11/11/08 www.cbpinsure.com

212 FFS Trustmark Insurance Co. 400 Field Drive

Lake Forest, IL 60045

800.366.6663

708.615.1500

61425 was Benefit Trust Ins.

213 PPO Covenant Administrators, Inc. (PPO) PO Box 105738

Atlanta, GA 30348

770.239.6230 58102

214 TPA Risk Benefit Management Services, LLC

(RBMS)

PO Box 241569

Anchorage AK 99524

800.770.3740 91176 11/11/08 www.rbnsllc.com

215 Oxford Life Insurance Company PO Box 46518

Madison, WI 53744

877.469.3073

216 FFS Humana Health Insurance Co. of Florida, Inc. PO Box 19080.F


800.457.4708 69671 61101

217 United World Life Insurance Company 3316 Farnam Street

Omaha, NE 66175

877.617.5587

218 RX Rocky Mountain Health Plan (RMHP) aka

WellDyne RX

7472 South Tucson Way, Ste 100

PO Box 4517, Englewood Co

80155

888.479.2000 008878 11/11/08 www.rmhp.org

219 RX Claims Pro PO Box 577

Southfield, MI 48075

800.837.9600

220 Health New England One Monarch Place, Suite 1500

Springfield, MA 01144.1500

800.310.2835

221 Qual Care PO Box 249

Piscathaway, NJ 08855

800.992.6613 23342

222 Medica PO Box 659752

San Antonio, TX 78265

800.952.3455

223 SI MedCost Preferred (Coastal Healthcare Group) PO Box 25437

Winston.Salem, NC 27114

800.824.7406

224 SI Southern Benefits

Southern Electric Health Fund

3928 Volunteer Drive


615.899.2593 See also: A66 & B30

225 Health Services Foundation PO Box 2109

Livermore, CA 94551

510.449.7070

226 Master Health Plan PO Box 1527

Augusta, GA 30903.1527

706.863.5720

227 FFS Monumental General Insurance Co. 1111 N. Charles St.

Baltimore, MD 20201

800.854.0186

228 Physician Plus Ins. Co. PO Box 909953

Milwaukee, WI 53209

800.545.5015 39156

229 PPO Self Insured Plans, LLC 1016 Collier Center Way, Suite

200

Naples, FL 34110

239.403.7884 36404 05.25.07

230 FFS Pyramid Life Insurance Co. PO Box 3237

Scranton, PA 18505

913.722.1110 68284 Health Claims Processing

See also #251

http://www.rbnsllc.com/

March 9, 2015 10

SC


CHANGE

NOTE

231 FFS Savers Life Insurance Co. 8064 North Point Blvd.


910.759.3888

232 General Adjustment Bureau (GAB) PO Box 81808

Atlanta, GA 30366

404.457.9555

233 Sterling Life Insurance Company

Health Plan Operations

PO Box 5348


800.688.0010

234 DEN AlwaysCare Benefits Inc. PO Box 80139

Baton Rouge, LA 70898

888.729.5433 STR01 11/13/08 www.alwayscarebenefits.com

235 SI Shaw Industries PO Box 10

Dalton, GA 30722

800.321.1855

236 FFS Guarantee Trust Life Insurance Co. of America 1275 Milwaukee Avenue

Glenview, IL 60025

800.338.7452

237 FFS Guardian Trust Life Insurance of America 201 Park Avenue

New York, NY 10003.1605

800.873.4542

212.598.8000

64211 Home – individual;

Regional – group

238 PPO Horizon Healthcare PO Box 1028

West Trenton, NJ 08628.0230

800 792 3666 22304 PPO for several unions

239 FFS Horace Mann Life Insurance Co. PO Box 20487

Springfield, IL 62708

800.999.1030

217.789.2500

64513

240 TPA Starbridge PO Box 55270

Phoenix, AZ 85078-5270

800-308-5948 67784 08.29.07 Was Star Administrators

241 Life Reinsurance Company PO Box 792070


800.229.1024

242 TPA Heller Associates 8228 Mayfield Rd Ste. 5B

Chesterland, OH 44026

440.527.2955

243 FFS Life & Casualty Insurance Co. of Tennessee American General Center

Nashville, TN 37250

615.749.2000

244 Sterling Investors Life Insurance Co. PO Box 10844

Clearwater, Fl 33757.8844

877.604.5240

245 TPA Coventry Health Care PO Box 8400

London, KY 40742

800.937.6824 87043 was First Health

246 RX Coventry Health Care RX PO Box 8400

London, KY 40742

800.937.6824 87043

247 Employers Direct Health 5050 Spring Valley Rd.

Dallas, TX 75244

800.550.8009 75232 was First Intergrated Health

248 FFS New England Financial 25145 Country Club Blvd.

North Olmsted, OH 44070.5300

800.255.8063 Health Plan Services

Also see #360

249 First Health (Workers Comp. only) PO Box 23070

Tucson, AZ 85735

800.554.4954 87043

250 RX Ideal Scripts (division of National Employee

Benefit Companies (NEBCO)

144 Metro Center Blvd

Warwick RI 02886

800.717.6614 11/11/08 www.idealscripts.com

251 Pymarid Life Insurance Co.

Medicare Supplemental Plan G

PO Box 12922

Pensacola, FL 32591.2922

800.444.0321 See also #230

252 Wellnet Healthcare 57 Street Rd.

South Hampton PA 18966

800.727.1733 610415 11/13/08 www.wellnethealthcare.com

http://www.wellnethealthcare.com/

March 9, 2015 11

SC


CHANGE

NOTE

253 TPA American Sterling Insurance Services P.O. Box 26103

Overland Park, KS 66225

877.292.6037

913.498.9090

254 FFS PM Group Life Insurance Co.

(Pacific Mutual)

PO Box 2890

Newport Beach, CA 92658.9010

714.640.3011 67466

255 FFS Pan American Life Insurance Co. PO Box 60219

New Orleans, LA 70160

504.566.1300 67539

256 TPA Benicomp 8310 Clinton Park Dr.

Ft. Wayne IN 46825

800.837.7400 N/A 12/4/08

257 RX Pharmacy Network National of North Carolina 4000 Old Wake Forest Dr, Ste

101, Raleigh, NC 27609

800.331.7108

258 TPA Diversified Administration Corp. P.O. Box 299

Marlborough, CT 06447

888. 322.2524

259 FFS CNA Healthcare Partners PO Box 34197

Little Rock, AK 72203

800.508.3772

260 TPA NCAS (National Claims Administrative

Services)

PO Box 10136

Fairfax VA 22038.8022

866 219.9292 75190

261 TPA UICI Administrators PO Box 30087

Reno, NV 89520.3087

800.315.3440 74223

262 PPO CAIC (Continental American Insurance Co) PO Box 6080-179

Mission Viejo CA 92690-6080

888.524.8778 N/A 12/4/08 SC based company: CAIC, PO Box 427,

Columbia SC 29202 800-433-3036

263 FFS American Insurance Co. of Texas/National

Financial

777 Main St. #900,


800.725.1407 81949

264 MA

HMO

Health America P. O. Box 7089

London, KY 40742

800.788.8445 25126

265 MA

PFFS

Today’s Option

Marquette Life

PO Box 391883

Cambridge MA 02139

866.222.5137 48055 01.09.08 www.todaysoptions.com

266 TPA ACMG Administrators of SC 2570 Technical Drive

Miamisburg, OH 45342

800.232.6242

267 TPA National Claims Administrative Services

(NCAS)

PO Box 220887


704.364.3865 75191

268 MS Marquette National Life Insurance Co. PO Box 12148

Pensacola, FL 32591

800.934.8203

269 TPA Epoch Group, The PO Box 12170


800.255.6065

270 TPA

PPO Preferred health Plan of the Carolinas PO Box 220397

Charlotte NC 28222

866.636.0239 61106 12/4/08

271 TPA American Benefit Plan Administrators 2200.B Rosselle St.


800.468.5126

904.353.7555

34187

272 SI Alliance Health Benefit Plan 1628 11th Street, NW

Washington, DC 10001

800.572.9096

202.939.6325

273 PPO Central Benefits USA (CenBen USA) PO Box 619059

Dallas TX 85261

800.772.5924 31118 12/29/08 www.centralbenefits.com

274 CDPHP (Capital District Physicians Plan) PO Box 66602

Albany, NY 12206.6602

518.641.3500 12X03

SX065

Non.Participation Payer

Transitional Payer

March 9, 2015 12

SC


CHANGE

NOTE

275 Dormant

276 Plan Handlers 930 Canterbury Place

Escondido, CA 92025

800.538.5512

277 FFS United American Insurance Co. 3700 S. Stonebridge Drive

McKinney, TX 75070.5937

214.328.2841 92916

278 SOLO

PPO

Rocly Mountain Health Plan PO Box 10600

Grand Junction CO 81502

800-854-4558 84065 1/8/09 www.rmph.org

279 FFS United Insurance Company of America 1 East Wacker Drive

Chicago, IL 60601

800.777.8467

312.661.3669

69930

280 RX CareMark PO Box 686005


800.841.5550

281 TPA Health Network America/Triveris PO Box 307

Eatontown, NJ 07724

800.337.1421 2.26.07 20199

282 Washington National Insurance Co. PO Box 1939

Carmel, IN 16082.1939

800.275.1896

283 MA

FFS

Guardian Healthcare Medicare Advantage PO Box 4197

Scranton PA 18505

866-850-1256 77010 1/9/09 Electronic claims can be filed March 2009

284 TPA Amerihealth Administrators 720 Blair Mill Rd.

Horsham, PA 19044

800.345.4017 54763

285 FFS Woodman of the World Life Insurance Society Woodmen Tower, 1700 Farnam St

Omaha, NE 68102

800.582.0122

402.342.1890

286 TPA Healthe Exchange (TPA for Cerner Health) PO Box 165750


800.231.4015 20356

287 TPA Community Health Plan PO Box 14467


888.800.8717 90010

288 TPA First Administrators (a Subsidiary of Wellmark

Administrators)

PO Box 9120

Des Moines, IA 50396

515.243.3210

289 AFTRA Health Fund

(Amer. Fed. of TV\ & Radio Artists)

261 Madison Ave.

New York, NY 10016

800.562.4690 13346

290 FFS Federated Mutual Insurance Co. (Regional) PO Box 31716

Tampa, FL 33631.3716

813.287.0155 41041 Home: Owatonna, MN

800.533.0472

291 SI NALC Health Benefit Plan (Letter Carriers) 20547 Waverly Court

Ashburn, VA 22093

888.636.6252 53011 Coventry Health Care

292 PPO Wellmark Administrators(PPO) PO Box 9901

Sioux City, IA 51102

800.526.5710

293 Dormant

294 FFS Bridgestone/Firestone Co. 1200 Firestone Parkway

Akron, OH 44317.0001

330.379.7000

295 TPA Medical Benefit Administrators 5940 Seminole Center Court

Madison, WI 53711

608.273.1776

296 FFS Reserve National Insurance Co. PO Box 26620


800.654.9106 68462

http://www.rmph.org/

March 9, 2015 13

SC


CHANGE

NOTE

297 FFS Amalgamated Life Insurance

(AMAL Cotton General)

730 Broadway

New York, NY 10003

800.543.4723

212.473.5700

13550

298 RX Smith Premier Pharmacy Plan Claims Department; PO Box 5824


800.247.4526

299 TPA Alicare PO Box 14447

New York, NY 10116.1447

212 539 5115 13550 Affiliate of #297

Amalgamated Life Ins.

300 TPA Benefit Administrators, Inc. PO Box 6279

Erie, PA 16512

800.777.2524

301 TPA Benefit Plan Administrators PO Box 11746

Roanoke, VA 24022.1746

800.277.8973 37118

302 SI Government Employee Hospital Assn.

(GEHA)

PO Box 4665

Independence, MO 64051.4665

800.821.6136 44054

303 Preferred Health Plan, Inc. PO Box 24125

Louisville, KY 40224

502.339.7500 66106

304 Butler Benefit Service, Inc. 215 North Main St, Ste 800

Davenport, IA 52801

866.927.2200 42150

305 TPA Wells Fargo TPA, Inc PO Box 2801 Charleston, WV 25330.2801

866.869.5597 87815

06.05.07 Was Acordia National (C32) this code is now

dormant 11/6/08

306 FFS Union Labor Life Insurance 111 Massachusetts Ave., NW


800.443.8087

202.682.0900

69744

307 TPA Standard Security Life Ins. Co. of New York PO Box 828

Park Ridge IL 60068

866.513.1479 86304 01.29.08 Iacusa.com

308 FFS Great West Life Assurance Co. 8505 E. Orchard Rd.

Englewood, CO 80111

800.537.2033 80705 63665 Also see #313

309 TPA American Administrative Group, Inc. PO Box 5227

Lisle, IL 60532.5227

630.493.9252 37283

75240

Currently Healthsmart Benefits Solutions as of

12/30/13

310 TPA Advanced Data Solutions PO Box 723097

Atlanta, GA 31139

800.742.5246

311 TPA Benefit Planners, Inc. PO Box 690450


210.699.1872 74223

312 TPA National Benefit Administrators 1805 Sardis Rd., North, Ste. 103,

Charlotte, NC 28227

800.482.6736 56175

313 Great West Healthcare

aka Great West Life & Annuity

1000 Great West Drive,

Kennett, MO 63857

800.663.8081 80705 Also see #308

314 RX Pharmacy Advantage Network 50 Lennox Pointe

Atlanta, GA 30324

888.727.5560 RX only

315 TPA Thomas Cooper & Company PO Box 22557


803.722.2115 67466 BCBS uses Preferred Blue network

316 FFS Professional Insurance Corp. PO Box 1410


800.289.1122

904.354.7171

317 Employee Benefits Management Corporation 4789 Rings Road

Dublin, OH 43017

800.552.0455

318 FFS Klais & Company, Inc. 1867 West Market St.

Akron, OH 44313.6977

216.867.8443 34145

March 9, 2015 14

SC


CHANGE

NOTE

319 TPA Benefit Concepts, Inc. PO Box 608

King of Prussia, PA 19406

800.2202600

320 FFS Lamar Life Insurance Co. PO Box 880

Jackson, MS 39201

800.258.5542

321 SI American Postal Workers Union Plan(APWU) POB 10398, Scottsdale, AZ 85271

POB 1358, Glen Burnie, MD

21060


322 FFS Time Insurance Company PO Box 624

Milwaukee, WI 53203

800.8008463

414.271.3011

69477 39065

323 Lincoln Heritage Life Insurance Co. PO Box 10843

Clearwater, FL 33757.8843

888.586.8810

324 Health Reimbursement Management

Partnership (HRMP)

5 Hutchinson Dr.

Danvers, MA 01923

888.999.4767

325 PPO PersonalCare (Coventry Healthcare Plan) PO Box 7141

London KY 40742

800.562.5792 25146 1/20/09 www.personalcare.org

326 PPO Physicians Health Plan of Mid-Michigan PO Box 247

Alpharetta Ga 30009-0247

800-832-9186 07689 1/20/09 www.phpmm.org

main office: PO Box 30377, Lansing MI 48909

327 SI Mail Handlers Benefit Plan PO Box 8402

London, KY 40742


328 Provider Select, Inc. PO Box 330070


866.74.7766 60054

329 SI Smithfield Foods Healthcare PO Box 158

Smithfield, VA 23431

800.809.5916

330 SI Southern Baptist Convention 127 Ninth Avenue

Nashville, TN 37234

331 Conseco Health Insurance Company PO Box 66904


800.541.2254

332 PPO Health Plans, Inc.( a subsidiary of Harvard

Pilgrim Healthcare)

PO Box 5199

Westborough MA 01581

800-532-7575 44273 1/20/09 www.pbhi.com

333 RX Express Scripts PO Box 60773

St. Louis, MO 63146.0667

800.451.6245

334 SI Rural Letter Carrier Benefit Plan (National

Letter Carriers Assn.)

1630 Duke St., Suite 200

Alexandria, VA 22314

800.638.8432

703.684.5552

Claims: Mutual of Omaha

335 J.P. Farley Corporation PO Box 458022

Westlake, OH 44146.8022

440.250.4300 34136

336 CASEBP (Catskill Area Schools Employee

Benefit Program)

PO Box 220

Stamford, NY 12167

800.962.6294

800.541.7403

337 SI Board of Pensions of the Presbyterian Church

of USA

1027 Arch Street

Philadelphia, PA 19107.2398

800.345.7940

338 TPA Pittman & Associates PO Box 111047

Memphis, TN 38111

800.238.1344 37224

339 Celtic Individual Health PO Box 33839

Indianapolis, IN 46203.0839

800.477.7870

340 Inactive – Medicaid 6.08 UnitedHealthcare purchased John Deere Ins.

Co.

Also called Secure Horizons; Use #596

http://www.personalcare.org/

http://www.phpmm.org/

http://www.pbhi.com/

March 9, 2015 15

SC


CHANGE

NOTE

341 PPO Administrative Concepts Inc. 997 Old Eagle School Rd. Ste 215

Wayne PA 19087

888.293.9229 22384 1/30/09 www.admnconcepts.com

342 FFS Sun Life Assurance Co. of Canada One Sun Life Executive Park

Wellesley, MA 02181

800.225.3950

617.237.6030

79065 Attn: Medical Claims Dept.

343 TPA Group Benefits Administrators 411 Hackensack Avenue

Hackensack, NJ 07601

201.343.3003

344 AGIA Claims Department

(Tricare/Champus Supplement)

PO Box 9060

Phoenix AZ 85068-9060

800-882-5707 N/A 1/30/09 www.agia.com

345 Employees Benefit Services (EBS) PO Box 1929

Fort Mill, SC 29716.1929

800.242.1510

346 TPA Administrative Services, Inc. 2300 Henderson Mill Rd, Ste. 414

Atlanta, GA 30345

770.934.3953 59141 Home office: Miami, FL

347 Preferred Care Inc. (PCI) PO Box 1235

Frederick MD 21702-0235

888.264.1512 N/A 1/30/09 Limited Indemnity policy

www.preferredcareinc.net

348 TPA First Agency, Inc 5071 West H Ave

Kalamazoo MI 49009.8501

269.381.6630 08.28.07

349 Health Plan Select PO Box 382767

Birmingham, AL 35238.2767

800.293.6260

706.549.0549

350 TPA J.W. Carroll Administrators/

North American Administrators

PO Box 1984

Nashville, TN 37203

615.256.3561

351 FiservHealth – Wisconsin (now UMR) PO Box 8077

Wausau, WI 54402.8077

866.684.8090

877.233.1800

39026 See also #356 changed to UMR 2009

352 Fiserv Health – Colorado (now UMR) PO Box 720

Pueblo, CO 81002.0720

800.446.8182 95266 05.22.07 changed to UMR 2009

353 TPA One Health Plan of SC c/o Great West Life

Insurance

PO Box 190019

N. Charleston, SC 29419

800.314.9010

354 First Benefits Corporation PO Box 879

Anderson, IN 46015

317.778.8555

355 Activa Health Group 4350 E. Camelback Rd. #200

Phoenix, AZ 85018

602.468.9500

356 FiservHealth . Kansas (now UMR) PO Box 2697

Wichita, KS 57201

800.362.0788 62061 See also #351 changed to UMR 2009

357 Health Plan Services PO Box 3295

Tampa, FL 33630

800.237.7767

358 SI Bakery & Confectionery Union & Industry

Int’l. Health Benefits Fund

10401 Connecticut Ave., Ste 300,

Kensington, MD 20895.3960

301.468.3731

359 FFS North Carolina Mutual Life Insurance Co. 411 W. Chapel Hill St.

Durham, NC 27701

800.626.1899

919.682.9201

67032

360 FFS New England Financial PO Box 190019

N. Charleston, SC 29419

800.408.7681 Also see #248

361 MDI Government Health Services

(Corporate Office)

822 Highway A1A North Ste 310

Ponte Vedra Beach FL 32082

800.841.6288 52181 2/5/09 www.medint.com

362 MA

HMO

Guardian Healthcare PO Box 4197

Scranton PA 18505

866.850.1253 2/13/09

http://www.medint.com/

March 9, 2015 16

SC


CHANGE

NOTE

363 Pearce Administration PO Box 2437

Florence, SC 29503

888.622.6001

364 FFS Corestar / Reliastar (was Northwestern Life

Insurance Co.)

PO Box 1195


800.444.6965 41045

365 SI Gerber Children’s Wear, Inc. PO Box 2126


864.987.5200

366 RX Catalyst Rx (A Health Extras RX Co.) PO Box 1069

Rockville, MD 20849

800.997.3784

367 FFS Loomis Company 850 Park Road North

Wyomissing, PA 19610.7011

800.782.0392

368 Med Benefits System PO Box 177

South Bend, IN 46601

800.283.0505

369 American International Group PO Box 25050

Wilmington, DE 19899

800.688.7077 87726

370 TPA P5 Health Plan Solutions

Aka PF Electronic Health Services

PO Box 9554


877.474.0605 87068 05.17.06 Name & address change

371 TPA Icon Benefit Administrators, Inc. PO Box 53020

Lubbock, TX 79453.3070

800.658.9777

372 MediPlan PO Box 509

Fairlawn, NJ 07410

201.791.6000

373 FFS State Farm Insurance Co. 7401 Cypress Gardens Blvd.

Winterhaven, FL 33888.0007

941.325.3163 31053

374 Dormant

375 Restat PO Box 758

West Bend, WI 53095.0758

800.248.1062

376 POS Tufts Health Plan PO Box 9171

Watertown MA 02471-9171

800.462.0224 2/13/09 www.tuftshealthplan.com

377 TPA North American Administrators, Inc. PO Box 9501

Amherst, NY 14226.9501

378 Self Insurers Service Inc. 2218 South Priest Drive

Tempe, AZ 85282

379 SI Goodyear Tire & Rubber Co. Dept. 609, 1144 E. Market St.

Akron, OH 44316

380 TPA Benmark, Inc. PO Box 16767

Jackson, MS 39236

601.366.0596

381 FFS Provident Indemnity Life Insurance Co. PO Box 511

Norristown, PA 19401

800.883.3500

215.279.2500

382 MA Health Plan of Nevada PO Box 15645

Las Vegas NV 89114.5615

800.777.1840 09.06.07

383 FFS American Healthcare Alliance PO Box 8530

Kansas City, MO 64114.0530

877.284.0102 01066

384 FFS North American Benefits Network PO Box 94928

Cleveland, OH 44101.4928

800.321.4085 34159

http://www.tuftshealthplan.com/

March 9, 2015 17

SC


CHANGE

NOTE

385 SI Postmasters Benefit Plan 1019 N. Royal Street

Alexandria, VA 22314.1596

703.683.5585

386 FFS Assurance Health POB 2940

Clinton, IA 52733

800.444.6254 Was Fortis Health

387 TPA Primary Physicians Care PO Box 11088

Charlotte, NC 28220

704.523.2578 75196

388 PPO Nationalway Healthcare Association PO Box 6305


800.670.1202

389 Group Link PO Box 20593

Indianapolis, IN 46220

800.359.7408

390 SI Board of Pensions Evangelical Lutheran

Church in America

PO Box 59093

Minneapolis, MN 55499.0093

612.233.7651

391 POMCO PO Box 6329

Syracuse, NY 13217

800.234.4393 16111

392 TPA IBA Self Funded Group PO Box 51719

Kalamazoo, MI 49005.1719

800.336.1340

616.341.7390

Parent: Bronson Healthcare Grp.

393 Southern Benefit Services /

Fountainhead Administrators

PO Box 2568

Birmingham, AL 35202

37138

394 TPA P5 Health Plan Solutions PO Box 9554


877.474.0605 87068 05.14.07

395 TPA Pinnacle Claims Management, Inc. 1630 E Shaw Ave., Suite 190

Fresno CA 93710

800.649.9121 24735 11.26.07 Updated Payer Code—from incorrect 347

396 Macy’s HR Services PO Box 850958

Richardson TX 75085

800.337.2363 03.26.08 Retired employees insurance for Macy’s &

Bloomingdales. Paper claims only

397 RX Prime Therapeudic PO Box 64812

St. Paul, MN 55164

651.846.8370

398 MS Right Choice Benefits Administratiors

(AKA Epoch Group of St. Louis)

12250 Weber Hill Rd, Ste 100

St. Louis MO 63127

800.365.9036 28777 2/13/09 www.midlandschoice.com

399 TPA Pacific Life & Annuity PO Box 34799

Phoenix, AZ 85067

800.733.2285 67466

400 FFS BCBS State Employees Health Plan POB 100605, State Processing

Unit,

Columbia, SC 29260.0605

800.444.4311

803.736.9852

401 FFS BCBS of South Carolina POB 100300, Claims Processing

Unit, Columbia, SC 29202

803.788.8562

402 SI Federal Employee Group Plan (FEP) PO Box 600601


800.922.1710 BCBS of SC

403 MCO BlueChoice Medicaid of SC PO Box 6170

Columbia SC 29260

877.275.3256 07/14/08

404 FFS Bob Jones University 1700 Wade Hampton Blvd.


864.370.1800

ext. 5200

405 MS Marsh (Insurance Trust Plan – Delta retirees) PO Box 10432

Des Moines IA 50306-0432

877.325.7265 Dalrcbenefitplans.com

406 PPO Rural Carrier Benefit Plan PO Box 7404

London KY 40742

800.638.8432 25133 9/9/14 Coventry Healthcare

Updated to reflect new address & neic

http://www.midlandschoice.com/

March 9, 2015 18

SC


CHANGE

NOTE

407 Cinergy Health Incorporated 1844 N. Nob Hill Rd, #623

Plantation FL 33322

800.847.1148 23212 2/19/09 www.cinergyhealth.com

408 FFS Life Investors Insurance Co. of America PO Box 8043

Little Rock, AR 72203

501.376.0426 64130 aka AEGON

409 TPA Upstate Administrative Services 723 James St.

Syracuse, NY 13203

315.422.1533

410 FFS Safeco Life PO Box 34690

Seattle, WA 98124.1690

206.867.8000

411 Interplan Health Group

IHG or WellNet

PO Box 90613

Arlington, TX 76006

866.511.4757

07.20.07

412 Dormant

413 Allied Benefits System PO Box 909786

Chicago, IL 60690

800.288.2078 37308

414 SI National Telephone Cooperative Assn.

(NTCA)

1 Pack Square, BB&T Bldg., #300

Asheville, NC 28801.3457

704.252.9776 52104

415 FFS Weyco, Inc. South Central Preferred

PO Box 2347 York, PA 17405

517.349.7010 38232

416 PSY Companion Benefit Alternatives PO Box 100185

Columbia, SC 29202

800.868.1032

417 TPA July Products – medicare supplement 5 Gateway Center, Ste 60, Blvd of

the Allies, Pittsburg PA 15222

866.900.8322 n/a 2/27/09

418 Guardian Insurance Company PO Box 8007

Appleton, WI 54912.8007

800.685.4542

419 State Health Benefit Plan PO Box 38151

Atlanta, GA 30334

420 FFS CUNA Mutual Insurance Society PO Box 1648

Madison, WI 53701

800.548.9390

608.238.5851

62626

421 United Food & Commerical Workers Health &

Welfare Fund (medicare supplement)

Fund Office, 911 Ridgebrook Rd

Sparks MD 21152-9451

800.638.2972 n/a 3/3/09 www.ufcwnationalfund.org

422.

431

SI Self Insureds

432 M.Plan Cardinal Health PO Box 357

Linthicum MD 21090.0357

800.675.2605

765.751.3060

Benefits

Pre Cert

433 FFS Companion Life Insurance Co. of South

Carolina

PO Box 100102


800.753.0404

434 TPA Piedmont Health Alliance 616 Bonham Court

Anderson, SC 29621

864.375.9661

435 Seabury & Smith Insurance Company, Inc. PO Box 2545

Nashville, TN 37219

800.582.2498 13310

436 TPA Davis-Garvin Agency #1 Fernandina Court

Columbia, SC 29212

803.732.0060

437 FFS New Era Life Insurance Co. PO Box 4884

Houston, TX 77210.4884

800.552.7879

March 9, 2015 19

SC


CHANGE

NOTE

438 FFS MAMIS Life & Health Insurance Co.

Mid Atlantic Medical Services

4 Taft Court

Rockville, MD 20850

800.441.6267 60321

439 Union Security Insurance Company PO Box 52033

Hazelwood, MO 63042

800.444.6254 70408

440 HMO Health Net, Inc.(HMO) PO Box 14702

Lexington, KY 40512

800.641.7761

441 SI Federal Mogul Healthcare PO Box 1966

Detroit, MI 48235

313.354.7700

442 FFS GE Life & Annuity Assurance Co. PO Box 6700

Lynchburg, VA 24505

800.253.0856

443 PPO Coventry HealthCare of Kansas PO Box 7109

London KY 39026

866.785.8077 25133 3/3/09 www.chckansas.com

444 National Disaster Medical System (NDMS) 68195

445 HMO Carolina Care Plan (use 822 Medical Mutual

of Ohio) This plan has been bought out.

PO Box 100234


800.315.3143

800.232.3143

57105 04.01.08 (SuperMed Network)

Plan bought out June 2009

446 TPA Employee Benefit Services, Inc. dba Key

Benefit Admin

PO Box 97

Charleston, SC 29402.0097

800.999.8853

803.577.8051

37216 BCBS uses the Preferred Blue network

447 MA

HMO

Health Net

Aka Health Net of AZ)

PO Box 14700

Lexington, KY 40512.4225

800.438.7886 06108 05.29.07

448 Assurant Health Insurance PO Box 42033

Hazlewood, MO 63042

800.553.7654

39065

449 IND United Service Assoc. for Healthcare PO Box 200848

Arlington TX 76006

800.872.1187 09.12.07

450 Deseret Secure ( Medicare Advantage PFFS) PO Box 45530

Salt Lake City UT 84145-0530

877.220.0110

800.777.3622

3/3/09 www.dmba.com

451 TPA Assurecare 340 Quanringle Blvd.

Boiling Brook, IL 60440

800.759.7422

452 PPO Cigna International Expatriate Benefits PO Box 15050

Wilmington DE 19850

800.441.2668 62308 3/10/09 www.cigna.com

453 MA

PFFS

Blue Cross Anthem Medicare Advantage 2100 Corporate Center Dr.

Newbury Park CA 91320.1431

800.676.2583 10.05.07 Bill thru local Blue Cross Plan

454 SI International Union of Operating Engineers

#25

166 West Kelly St.

Metuchen, NJ 08840

908.548.6662

455 PPO Alaska Teamster Trust 520 E 34th Avenue, Suite 107

Anchorage, AK 99503.4116

800.478.4450 93044 05.22.07

456 PPO First Health ( A Coventry Health Care

Company)

PO Box 21680

Eagan MN 55121-0680

866.477.5465 75276 3/10/09 www.firsthealth.com

457 Commercial Travelers

Attn: College Claim Department

70 Genesse St

Utica NY 13502

800-756-3702

N/A 3/11/09 www.commercialtravelers.com

458 PPO Association Benefit Plan

(Medicare)

Charlotte Health Care Svc Cntr

POB 668587

Charlotte NC 28266-8587

800.634.0069 71472 3/11/09 theintelligentchoice.com

http://www.cigna.com/

March 9, 2015 20

SC


CHANGE

NOTE

459 SI Glass Motors & Plastic (GMPA) 5245 Big Pine Way, SE

Fort Myers, FL 33907

813.936.6242

460 FFS Morris Associates PO Box 50440


800.950.6789

461 MA Evercare PO Box 31350

Salt Lake city UT 84131-0350

888.866.8298 87726 3/19/09 www.uhconline.com

462 PPO 1st Medical Network PO Box 724317

Atlanta GA 31139

888.980.6676 29076 www.1stmn.com

463 SI Tim Bar Corporation PO Box 449

Hanover, PA 17331

717.632.4727

464 International Medical Group 407 N. Fulton St.

Indianapolis IN 46202

800.628.4664 03.26.08 Placed back in active status

465 TPA Inter Care Benefit Systems PO Box 3559

Englewood, CO 80155.3559

303.770.5710

466 RX Value RX 30445 Northwest Hwy, Ste. 300,

Farmington Hills, MI 48334

800.347.8777

467 Harrington Benefit Services PO Box 182173

Columbus, OH 43218.2173

800.848.2664

468 Phoenix Healthcare PO Box 150809

Arlington, TX 76015

800.397.6241

469 SI American Assn. of Retired Persons (AARP) PO Box 13999

Philadelphia, PA 19187.0216

470 SI Yoder Brothers 1001 Lebanon Road

Pendleton, SC 29870

864.646.8331 Attn: Medical Benefits

471 RX Advance Prescription Mgt. PO Box 819.56

Dallas, TX 75381.9056

800.864.2352

472 SI NHC Benefit Plan PO Box 1398

Murfreesboro, TN 37130

615.890.2020 62124

473 SI International Mission Board (IMB)

Medicare supplement

PO Box 6767

Richmond VA 23230-0767

804.219.1585 N/A 4/8/09

474 RX Diversified Pharmaceutical PO Box 169052

Duluth, MN 55816

800.233.8065

475 TPA Benefit Assistance Corp. PO Box 950

Hurricane, WV 25526

304.562.1913

476 SI Central States, Southeast & Southwest Areas

Health/Welfare Fund

8550 W. Bryant Mawr Ave.

Chicago, IL 60631

800.323.5000

847.518.9800

37214

477 FFS Mega Life & Health Insurance Co. PO Box 982017

N. Richland Hills, TX 76182

800.359.4440 97055 97055

478 TPA Smith Administrators PO Box 61125


800.67.2582 02057

479 Primextra PO Box 207

Twinsburg, OH 44087

800.433.4893

480 HMO Coventry Healthcare of the Carolinas

(Wellpath)(HMO)

PO Box 7715

London, KY 40742

800.889.1947 25127

March 9, 2015 21

SC


CHANGE

NOTE

481 PPO Benovation 3481 Central Parkway, Ste 200

Cincinnati OH 45223

800.681.6912 N.A 4/8/09 www.my-benovation.com

482 Coventry Healthcare of Georgia PO Box 7128

London KY 40742


483 TPA Cooperative Benefits Administrators PO Box 6249

Lincoln, NE 68506

402.483.9250 52132

484 Integrity Benefits Network 640 Powder Springs, # E.28

Marietta, GA 30064

404.691.0611

485 EPO Providence Health Plan PO Box 3125

Portland OR 97208-3125

800.878.4445 SX133 4/10/09 www.providence.org

486 MA

PFFS

Preferred Care PO Box 22920

Rochester NY 14692.2920

800.999.3920 01.23.08 www.prefferedcare.org/usacarehtml

*Notice NEIC is alpha. Ret. Kodak employees

487 FFS Piedmont Insurance Company PO Box 979

Marion, SC 29571

803.423.5541 80578

488 TPA American Benefits Management PO Box 667

Chargin, OH 44022

404.321.9200 34187

489 Dormant

490 Sheet Metal Local 20 PO Box 42489


800.248.2141 N/A 4/16/09

491 Vision Service Plan PO Box 997100

Sacramento, CA 95865.7100

800.622.7444

492 Lt11 - Lifetrac Network 111100 Wayzata Blvd

Minneapolis MN 55305

4/16/09 Special transplant contract

493 MS United Teacher Assoc. Insurance Co.

Great American Life Ins. Co.

PO Box 30010

Austin, TX 78755.3010

800.880.8824 63479 Paper claims only

Assigned incorrectly to 497

494 PPO Insurance Management Administrators (IMA) PO Box 71120

Bossier City LA 71171.1120

800.742.9944 11.26.07 www.imala.com

Fax claims to 318.747.5047

495 RX National Prescription Network PO Box 2187

Clifton, NJ 07015

800.462.6035

496 SI AVMA Group Health & Life Insurance Co. PO Box 909720

Chicago, IL 60690


497 Texas International PO Box 11007

Winstong Salem, NC 27116

866.370.4711 Assigned incorrectly (see 493)

498 TPA Carolina Benefit Administrators PO Box 3257


800.476.1555

864.573.6937

68195 BCBS uses the Preferred Blue network

499 TPA Employee Benefit Consultants PO Box 928

Findlay, OH 45839

800.634.8816 37257

500 DEN Delta Dental PO Box 1809

Alpharetta, GA 30023.2651

800.445.9090

501 FFS Union Fidelity Insurance Co. 4850 Street Road

Trevose, PA 19049

800.523.5758 62596

502 MA HIP Health Plan

(Health Insurance Plan of Greater NY)

55 Water St

New York NY 10041

866.447.9717 55247 www.hipusa.com

updated 3.31.8

http://www.my-benovation.com/

http://www.providence.org/

http://www.prefferedcare.org/

http://www.imala.com/

http://www.hipusa.com/

March 9, 2015 22

SC


CHANGE

NOTE

503 ASRM (American Special Risk Management) 509 South Lenola Road, Bldg.

Two

Moorestown, NJ 08057

800.359.7475

504 Dormant 6/08 04.31.07 Was M-Care; no longer in business

Use #902

505 TPA Associated Administrators PO Box 27806

Baltimore, MD 21285.7806

800.638.2972

506 TPA Employee Benefit Plan Administrators (EBPA) PO Box 2000

Hampton, NH 03842

800.258.7298 03038

507 FFS Central States Health & Life Co. of Omaha PO Box 34952

Omaha, NE 68134.9832

800.541.2363

402.397.1111

61751 36215

508 FFS Group Health Insurance (GHI) PO Box 2833 (Inpatient)

New York, NY 10036

212.501.4447 13551 Outpatient; PO B. 3000

New York, NY 10036

509 FFS Equitable Life & Casualty Insurance Company PO Box 2460


800.352.5150

802.579.3400

62952

510 TPA Equitable Plan Services PO Box 720460


800.749.2631 73126

511 CIGNA Behavioral Health Inc. 11095 Viking Dr., Ste. 350

Eden Prairie, MN 55344

800.442.4227 SX071

512 ST11 - Strategic Health 9501 NE 2nd Avenue

Miami Shores FL 33138

4/16/09 Special transplant contract

513 TPA Value Behavioral Health PO Box 1079

Troy, NY 12181.1079

800.738.7797

518.270.1890

514 JLT Services (TPA for NY Life) PO Box 1511

Latham, NY 12110

800.793.3773

515 Life of the South Insurance Company PO Box 45237


800.661.6385

516 RX Direct Reimbursement Benefit Plans PO Box 450669

Atlanta, GA 30345

404.315.8652

517 Uniform Medical Plan PO Box 34850

Seattle, WA 98124

800.762.6004 75243

518 SI National Asbestos Workers Medical Fund 8401 Corporate Drive

Landover, MD 20785

519 Dormant

520 New Jersey Carpenters PO Box 7818

Edison, NJ 08818

800.624.3096 22603

521 Alliance PPO, Inc. PO Box 934

Frederick, MD 21705

800.342.3289 52148 52149

522 SI National Automatic Sprinkler Industry Fund

Office

800 Corporate Drive

Landover, MD 20785

301.577.1700

523 TPA APA Partners, Inc PO Box 1506

Latham, NY 12110.8006

800.833.3650 16140

524 TPA HealthFirst PO Box 130217

Tyler, TX 75713

800.477.8957 75234

March 9, 2015 23

SC


CHANGE

NOTE

525 FFS Conseco Medical Insurance Co. PO Box 1205

Rockford, IL 61105

800.947.0319

526 Aultcare PO Box 6910

Canton, OH 44706.0910

800.505.2858

527 Value Options PO Box 1920

Latham, NY 12110

800.278.3252

528 MA

HMO

Kaiser Permanente PO Box 190849

Atlanta, GA 31119

800.611.1811

404.261.2590

93079

91617

Paper copies to PO Box 373150

Denver CO 80237 or Atlanta address

529 TPA Anthem Health 3575 Kroger Blvd, Ste. 400

Duluth, GA 30316

800.888.1966

530 TPA

MS

MS

Universal Benefits Corporation

(City of Bridgeport Retiree Medical Plan)

PO Box 97

Scranton, PA 18504.0097

800.854.0186

531 TPA Mary Black Health Network 1690 Skylyn Dr., Ste. 130


864.573.3537

864.573.3490

532 TPA American Medical Security PO Box 19032

Greenbay, WI 54307

800.232.5432 81400

533 PPO Physicians Care Network, Inc.(PPO) (SCMA) PO Box 11188, Cola., SC 29211

or

103 S. Pine St., Spartanburg,

29302

803.771.0077 56142

534 RX Provantage Prescription Benefit Mgt. Services PO Box 846

Brookville, WI 53008.0846

414.784.4600

535 PPO CHP Direct/SuperMed

(Premier Health Systems Inc.)

PO Box 1640

Columbia SC 29202-1640

800.258.3152 90441 4/29/09 www.premierhealth.com

536 TPA CWI ManageMed (Claimsware Inc.) PO Box 6125


800.992.8088

803.234.8200

Was Claims ManageMed

537 Kaiser Permanente.Ohio Region PO Box 5316.9774

Cleveland OH 44101.0316

800.686.7100

34092 10.31.07

538 TPA Penn General Services PO Box 720677


800.444.1535

539 PPO SuperMed/Medical Mutual Insurance of Ohio

(NAS accounts)

PO Box 94648

Cleveland OH 44101

800.362.1279 90440 4/29/09 www.medmutual.com

540

FFS Liberty National Life Insurance PO Box 10592


205.325.2575 65331

541 Division of Children w/ Special Health Care

Needs (SC DHEC)

PO Box 101106

Columbia SC 29011

803.898.0748 Paper claims only. Handled by individual

county.

542 TPA Third Party Administrators/ American Benefit 1733 Park St., #300

Naperville, IL 60563

800.736.7872

543 ACHA/Careington International Corporation PO Box 2568

Frisco TX 75034

800.290.0523 www.careington.com

544 PPO ETHIX Southeast NYLCARE Health Plan(PPO) PO Box 222097

Charlotte, NC 28209

704.364.8215

545 HMO Molina Healthcare of Ohio (Medicaid) PO Box 22712

Longbeach CA 90801

800.642.4168 20149 5/4/09 www.molinahealthcare.com

546 TPA Risk Management Services PO Box 6309

Syracuse, NY 13217

http://www.premierhealth.com/

http://www.medmutual.com/

http://www.careington.com/

http://www.molinahealthcare.com/

March 9, 2015 24

SC


CHANGE

NOTE

547 PPO Harrington Health PO Box 30544


800.235.7160 62061 5/13/09

548 CompBenefits Insurance Co. PO Box 804483


800.594.0977 32481

549 SI Wal-Mart Stores Group Health Plan 702 South West 8th St.

Bentonville, AR 72716.8086

501.621.2929

550 TPA Employee Security Inc. 7125 Thomas Edison Dr. Suite

105

Columbia MD 21046

800.638.1134 NO 04.08.08 Paper Claims Only

551 TPA Cooperative Managed Care Svc., LLC St.

Joseph & St. Vincent CMO Claims

PO Box 502530


866.873.4516 35199

552 TPA CoreSource, Inc. 6100 Fairview Road, Ste. 1000

Charlotte, NC 28210

800.327.5462

704.552.0900

71063

553 Healthscope Benefits, Inc. PO Box 8076

Little Rock AR 72203

800.827.7026

554 SI Diamond G Employee Benefit Trust PO Box 1360

Greenville, TN 37744

615.639.6145

555 MS Philadelphia American Life Insurance

Company

PO Box 4884

Houston TX 77210-4884

800.552.7879 N/A 5/20/09 www.neweralife.com

556 Unified Group Services PO Box 10

Pendleton IN 46064


557 Americorps PO Box 33757


800.847.8217

558 Dormant

559 SI Carolinas Hospital System Benefit Plan PO Box 100569

Florence, SC 29501.0659

803.661.3942

560 TPA Allen Medical Claims Administrators, Inc. PO Box 978

Ft. Valley, GA 31030.0978

800.825.5406

561 FFS Phoenix Home Life Mutual Insurance PO Box 6777

Greenfield, MA 01302

800.451.2513 67814

562 TPA Health Claim Services, Inc. PO Box 237940

Boca Raton, FL 33427.3940

800.222.3560

954.480.2744

563 TPA Administrative Service Consultants 3301 E. Royalton Rd, Bldg. D

Broadview Heights, OH 44147

800.634.8816

564 Multinational Underwriters

(individual travelers policy)

PO Box 863


800.605.2282 N/A 5/26/09 www.mnui.com

565 TPA United Benefits Inc. PO Box 2480

Daytona Beach, FL 32115.2480

800.434.4890 United Benefits Inc. bought

Poe & Brown Benefits

566 Unified Group Services PO Box 10

Pendleton IN 46064


567 Eastern Benefit Systems 200 Freeway Drive E

East Orange, NJ 07018

800.524.0227

568 TPA Health Risk Management, Inc. PO Box 1479


800.422.0055 55438

http://www.neweralife.com/

March 9, 2015 25

SC


CHANGE

NOTE

569 PPO Maryland Physicians Care PO Box 61778

Phoenix, AZ 85082

800.953.8854 22348

570 SI SAMBA Health Benefit Plan

(Special Agents Mutual Ben. Assoc.)

PO Box 8600

London, KY 40742

800.638.6589 37259

Contr

act

Disci

pline

staff

have

provi

ded

the

follo

wing

infor

matio

n in

respo

nse

to

your

call

regar

ding

the

UB.92

being

repla

ced

by

the

UB.04

.

The

names

of

the

DHEC

Progr

am,

Progr

am

staff

,

phone

and

e.mai

571 TPA CoreSource, Inc. PO Box 8215

Little Rock, AR 72221.8215

888.604.9397 75136

572 Health Trans, LLC 8300 E Maplewood Ave

Greenwood Village CO 80111

877.839.8119 009117 03.27.08 RX Claims Only

573 St. John's Claims Administration PO Box 14409

Springfield, MO 65814

877.875.7700 37264

574 City of Amarillo - Group Health PO Box 15130

Amarillo, TX 79105.5130

806.378.4235

575 Wisconsin Electrical Employees PO Box 2430

Brookfield, WI 53008.2430

608.276.9111

576 Sioux Valley Health PO Box 91110

Sioux Falls, SD 57109

800 752.5863

577 PFFS HealthMarkets Care Assured

Chesapeake Life Insurance

PO Box 69349

Harrisburg Pa 17110

877.219.5460 62295 01.22.08 www.hmcareassured.com

578 TPA Professional Administrators, Inc. 3751 Maguire Blvd., Suite 100

Orlando, FL 32814

800.741.0521

579 RX Anthem Prescription Management PO Box 145433


800.662.0210

580 FFS World Insurance Co. PO Box 3160

Omaha, NE 68103.0160

800.786.7557

402.496.8000

70629 75276

581 RX Alta RX PO Box 30081


800.998.5033

582 FFS USAA General Indemnity Co.

USAA Life Insurance Co.

9800 Fredericksburg Rd.


800.531.8000

800.531.9017

583 TPA One Nation Benefit Administrators PO Box 528

Columbus, OH 43216

800.824.6796 was Anthem Benefit Administrators (name

change)

584 FFS Golden Rule Life Insurance 7440 Woodlawn Dr.


800.225.5476

618.943.8000

62286 37602

585 Plumbers & Streamfitters Welfare Fund Local

21 Health Plan

1024 McKinley St

Peekskill NY 10566

914.737.7220 N/A 6/2/09

586 TPA MCA Administrators (Managed Care of

America

Manor Oak Two, Ste 605

1910 Cochran Road

Pittsburgh PA 15220

412-922-0780 25160 8/26/08 Previously named Diversified Group

Administrators, Inc. PO Box 330

Canonsburg, PA 15317.0330

587 RX Future Scripts PO Box 419019 Dept. 382

Kansas City MO 64141

888.678.7012 PBM

Bin #

600428

04.30.08 www.argushealth.com

username: phrminfo

password: phrmrx2u 588 TPA Automated Benefit Services Inc. PO Box 321223

Detroit MI 48232-1223

800.275.1896 38259 6/2/09 www.abs-tpa.com

589 Poly America LP 2000 W. Marshall Dr

Grand Prairie TX 75051

800.785.5301 32680 03.03.08

590 TPA Physicians Health Services PO Box 981

Bridgepoint, CT 06601

800.848.4747

http://www.argushealth.com/

March 9, 2015 26

SC


CHANGE

NOTE

591 FFS Old American Insurance Co. 3520 Broadway


800.733.6242

816.753.4900

Attn: Personnel

592 SI Contec 525 Locus Grove Rd.


864.503.8333

593 TPA Mutual Assurance Administrators, Inc. PO Box 42096


800.648.9652 37256

594 SI Norwest Financial 206 Eighth Street


515.243.2131

595 FFS AFLAC Incorporated 1932 Wynton Road

Columbus, GA 31999

800.992.3522

404.323.3431

596 MA

HMO

Secure Horizons

UnitedHealthcare of River Valley

3800 Ave. of the Cities, Ste 200

Moline IL 61235

800.435.1989 95378

597 SI Monarch Direct 2700 W. Plano Pkwy.

Plano, TX 75075.8205

Avon Rep. Group Ins. Prog.

598 WJB Dorn VA Medical Center 6439 Garners Ferry Road


803.776.4000

x4801

599 National Elevator Industry Health Benefits PO Box 477

Newton Square, PA 19073.0477

800.523.4702

600 Self.Payers

601 Hill.Burton (Category A)

602 Hill.Burton (Category B)

603 Other Indigent (Hospital Charity)

604 CHAMPVA PO Box 65024

Denver, CO 80206.5024

800.733.8387

605 Medically Indigent Assistance Program

606 Vocational Rehab. General 803.896.6577 Dependent on Referral Counselor

607 WPS TRICARE for Life PO Box 7889

Madison, WI 53707.7889

866.773.0404

608 Vocational Rehab. Disability

PO Box 80, W. Cola., 29171

PO Box 3090, Greenville 29602;

or 1064 Gardner Rd., Charleston

29407

803.896.6577

609 Commission for the Blind 1430 Confederate Ave.

Columbia, SC 29201

610 DHEC Cancer Diagnosis

611 DHEC Crippled Children 2000 Hampton Street

Columbia, SC 29204

612 DHEC Low Risk Maternity

March 9, 2015 27

SC


CHANGE

NOTE

613 DHEC High Risk Maternity PO Box 101106, Robert Mills

Complex, Cola., SC 29211

614 TRICARE PO Box 20200

Florence, SC 29502.2000

57106

615 DHEC Sterilization

616 Medicaid – Out.of.State

617 Medicare – Railroad (PGBA)

Professional . Part B

PO Box 10066

Augusta GA 30999

877.288.7600

618 Medicare Part A 61101 PalmettoGBA

619 Medicaid – SC POB 8809 (Crossover Claims);

POB 1458 (UB.92); Cola., SC

29202

803.253.6138 POB 1412 (HCFA 1500); Cola., SC 29202.8206

620 Medicare Part B Only PO Box 100190

Columbia, SC 29202

803.768.5568 61101 PalmettoGBA

621 Department of Corrections PO Box 21787

Columbia, SC 29210

622 Workmen’s Compensation Various Carriers

623 MA

HMO

Carolina Medicare Prime(HMO) 201 Executive Center Drive

Columbia, SC 29210

803.750.7473

800.868.6734

x 7473

624 Other Sponsor

625 DHEC Migrant Health

630 DHEC TB

627 DHEC Heart

628 DHEC Hemophilia

629 DHEC Family Planning

630 DHEC TB

631 Shriners

632 Crime Victims Sexual & Physical Abuse &

Vulnerable Adult

1205 Pendleton St., #401

Columbia, SC 29201

800.220.5370

633 Veterans Administration 12115

634 DHEC Cancer Screening

Mills/Jarrett Complex

PO Box 101106

Columbia, SC 29211

March 9, 2015 28

SC


CHANGE

NOTE

635 Medicare Part A – Mutual of Omaha Mutual of Omaha Plaza

Omaha, NE 68175

402.342.7600

636 Medicare Part B – Mutual of Omaha Mutual of Omaha Plaza

Omaha, NE 68175

402.342.7600

637 HMO SelectHealth.First Choice Medicaid HMO

Claims Processing

PO Box 7120

London, KY 40742

888.276.2020 23285

638 HMO United Healthcare Community Plan

Formerly Unison Health Plan(HMO)

250 Berryhill Rd, Cola, SC 29210

POB 1148, Monroeville, PA

15146

803.798.5852 11775 32006 3/7/11 Was Unison Health Plan

was Better Health Plans of South Carolina, Inc

639 HMO HealthFirst – Medicaid HMO 255 Enterprise Blvd., Ste. 20


864.455.1100

640 Highmark Medicare Services (HMS)

(replacesTrailBlazer Section 1011:

Undocumented Alien Program)

11/19/10 TrailBlazer Section 1011: Undocumented Alien

Program

Program replaced 11/29/10

641 CHAMPVA for Life PO Box 65024

Denver, CO 80206.9024

800.733.8387

642 TRICARE for Life PO Box 7053

Camden, SC 29020

866.835.7422

643 BCBS of Tennessee

(Medicaid/Medicare Claims Only)

730 Chestnut St


877.296.6189

644 BCBS of Georgia

(Medicaid/Medicare Claims Only)

PO Box 9907

Columbus, GA 31908

800.441.2273

645 MDA Medicaid Out.of.State – Managed Care See page 4.1

646 Medicare – CIGNA PO Box 671

Nashville, TN 37202

910.665.0338

615.244.5600

FI for NC, TN, ID

647 Crime Victims Other Than Sexual/ Physical

Abuse.Office of the Governor

Division of Victim Assistance,

1205 Pendleton St, #401, Cola.,

SC 29201

800.220.5370

648 MA Humana Gold Choice POB 14601


877.511.5000

649 Medicaid North Carolina

650.

695

Various County Sponsors see Page P.2

696 Out-of-State – GA

697 Out-of-State – NC

698 Out-of-State – Other

699 Out-of-State – VA

700 Medicare DMERC

701 Uni.Care Choice Health Benefits PO Box 2949

Cincinnati, OH 45201.2949

800.543.6700 65099

March 9, 2015 29

SC


CHANGE

NOTE

702 TPA Boon.Chapman Benefit Administrators, Inc. PO Box 9201

Austin, TX 78766.9201

800.252.9653 74238

703 TPA Tucker Administrators, Inc. 9140 Arrow Pt. Blvd. #200


704.525.9666

704 SI United Food & Commercial Workers Health &

Welfare Fund (UFCW)

1800 Phoenix Blvd, Ste. 310

Atlanta, GA 30349

800.241.7701 36659

705 APS Healthcare, Inc.

(American Psych Systems)

PO Box 1246

Rockville, MD 20849

800.752.7242 54160

706 Plumbers and Pipefitters

Local No. 421 Health & Welfare Fund

PO Box 840

Macon, GA 31202.0840

888.741.2673 See also #729; #C91

707 SI Dillon Yarn Medical Benefits PO Box 1247

Dillon, SC 29536

803.774.7353

708 PERFORMAX PO Box 61505

King of Prussia, PA 19406

888.554.7629 Also see #862

Performax in NY different payer

709 TPA Marsh Advantage America 145 N. Church Street, BTC 80


800.868.7526

710 TPA 21st Century Health & Benefits, Inc. 1845 Walnut St, 23rd Fl.

Philadelphia, PA 19103

800.533.9323

711 SI Laborers District Council PO Box 607

Jonesboro, GA 30237

404.477.1888

712 RX TDI Managed Care Services (RX only) 620 Epsilon Drive

Pittsburg, PA 15238

800.581.5300

713 PPO HCCUA – Health Care Credit Union Assoc. PO Box 260957

Plano TX 75023.0957

866.373.6366 08.30.07

714 Stowe Associates 2872 Woodcock Blvd, # 200

Atlanta, GA 30341

800.533.7896 58128

715 FFS United Healthcare Insurance Co.

aka United HealthCare Corp.

PO 1459, Minneapolis, MN

55440; PO 169050, Duluth, MN

55812

612.992.4050

800.526.2414

also see #113, #881, #947, #950

716 PPO Indecs Corp PO Box 668

Lyndhurst NJ 07071

888.446.3327 40585 09.17.07

717 MA

PFFS

MA

PFFS

USA Health Care (MVP Health Care) PO Box 22920

Rochester NY 14692-2920

800.999.3920 14165 6/08/09 www.preferredcare.org/usacare

718 RX RX Prime 900 Cottage Grove Road

Hartford, CT 06152.1121

800.622.5579

719 Florida Health Alliance PO Box 10269


904.354.8335

720 SI United Mine Workers Health & Retirement

Fund

Rt. 2, Box 218A

Big Stone Gap, VA 24219

721 United Resource Network PO Box 30758


877.801.3507 41194 08.27.07

722 FFS American Republic Insurance Company PO Box 21670

Eagan MN 55121-0670

800.247.2190

515.245.2000

67679

60836

42011 8/24/11 www.americanrepublic.com

723 FFS Carolina Continental Insurance PO Box 427


800.433.3036

803.256.6265

http://www.preferredcare.org/usacare

http://www.americanrepublic.com/

March 9, 2015 30

SC


CHANGE

NOTE

724 TPA Mutual Medical Plans PO Box 689

Peoria IL 61652

800.448.4689 N/A 6/08/09 www.mutualmedical.com

725 SI Dialysis Clinic, Inc. 203 Freemont Ave.


803.585.2046

726 FFS Insurance Services & Benefits, Inc. 3218 Hwy. 67, Ste. 218

Mesquite, TX 75150

800.878.3157

727 FFS Guarantee Mutual Life Co. 8801 Indian Hills Drive

Omaha, NE 68114

800.462.4660 Indiv. Claims paid by #543

728 RX General Prescription Programs, Inc. 127 East 59th St.

New York, NY 10022

800.341.2234

729 U.A. Local 447 (Plumbers and Pipefitters)

Health & Welfare Trust Fund

PO Box 191030

Sacramento, CA 95819.1030

916.457.0821 See also #706; #C91

730 PPO Georgia Healthcare Partnership(PPO) PO Box 16388

Savannah, GA 31416.3088

912.350.6710

731 PPO ADOVA Health PO Box 725549

Atlanta, GA 31139

866.470.4959

732 SI Hertz Claim Management 6116 Executive Blvd., Ste. 715

Rockville, MD 20852

301.881.8998

733 TPA Mountain Claims Management PO Box 1008

Fruitland, ID 83619

208.452.7979

734 PPO Strategic Outbursting Inc PO Box 241508

Charlotte NC 28224

888.836.7764 87043 09.17.07

735 PPO Integritas Benefit Group PO Box 1447

Cordova TN 38088

901.685.8980 20435 03.17.08 www.integritasbenefitgroup.com

736 Spectera Optical Care 2811 Lord Baltimore Drive

Baltimore, MD 21244.2644

800.638.3120

737 SI United Concordia Co., Inc.

(TRICARE Active Duty Dental Plan)

PO Box 898220

Camp Hill, PA 17089.8220

800.866.8499

738 PPO FHA.TPA Division PO Box 327810

FT Lauderdale FL 33332.9711

800.707.0501 10.22.07

739 Bollinger Inc PO Box 727

Short Hills NJ 07078

866.267.0092 www.bollingercolleges.com

intercollegiate health plan

740 RX Pharma Care PO Box 519

Lincoln, RI 02865

800.237.6184 RX only

741 PPO Spencer & Associates Insurance 1 S Limestone St, Ste 301

Springfield OH 45502

866.766.9016 N/A 6/29/09 www.afidllc.com

Limited medical multiplan network

742 MIDA Dental Plan 2000 Town Center, Ste. 2200


800.937.6432

743 TPA Employee Plans, Inc. PO Box 2362

Ft. Wayne, IN 46801.2362

219.436.1616 35112

744 HMO

MA

Senior Dimensions (product of Health Plan of

Nevada)

PO Box 15645

Las Vegas NV 89114-5645

800.925.7455 76342 7/1/09 http://www.seniordimensions.com

745 TPA Group Benefit Services 1312 Bellona Ave.

Lutherville, MD 21093.5456

800.638.6085

http://www.mutualmedical.com/

http://www.bollingercolleges.com/

http://www.afidllc.com/

March 9, 2015 31

SC


CHANGE

NOTE

746 TPA Med.Tac Claims PO Box 9110

Newton, MA 02160

800.347.9355

747 PPO PacifiCare PO Box 6099

Cypress, CA 90630

866.316.9776 95999 08.29.07

748 PPO Health Care Savings, Inc.(PPO) 4530 Park Road

Charlotte, NC 28209

919.828.1789 56142

749 TPA Gerber Life Insurance Co./

GM Underwriters Agency

PO Box 5004

Rochester, MI 48308.5004

800.521.2623 School Policies

750 Benefit Administrative Services PO Box 4509

Rockford, IL 61110

815.969.9663

751 TPA Polaris Benefit Administrators PO Box 1008

Delaware, OH 43015

614.436.8822

752 PPO Hygeia Corporation 15500 New Barn Rd, # 200.Br78

Miami Lakes FL 33014

800.591.2650

10.26.07

753 HMO Health Net PFFS

(Medicare replacement plan)

PO Box 2226

Augusta GA 30903-2226

800.977.8221 12X48 7/23/09 www.healthnet.com

754 TPA 1199 SEIU National Benefit Fund PO Box 933

NY NY 10108

888.819.1199 13162 04.30.08 www.1199nbf.org

755 TPA Total Benefits Services, Inc. PO Box 30180

New Orleans, LA 70190

800.596.3150

756 PPO Insurance Management Administrators (IMA) PO Box 71120

Bossier City LA 71171.1120

800.742.9944 11.26.07 www.imala.com

Fax claims to 318.747.5047

757 FFS J.C. Penney Life Insurance Co. PO Box 869090

Plano, TX 75086.0909

800.692.5246

758 HealthChoice PO Box 24870

Oklahoma City, OK 73127-0870

800.782.5218 8/5/09

759 MediPlus aka TROA PO Box 9126


800.242.2192

760 TPA Key Benefit Administrators PO Box 55210


800.331.4757 37217

761 Employee Benefit Strategies 229 E. Michigan Ave., Ste. 235

Kalamazoo, MI 49007

800.325.7477

762 MS Royal Neighbors of America PO Box 10850

Clearwater FL 33757-8850

877.815.8857 8/5/09 www.royalneighbors.com

763 TPA The Provident PO Box 31499

Tampa, FL 33631

800.525.7268

764 HMO

Care Link Health Plan PO Box 7373

London KY 40742.7373

800.348.2922

25139

10.31.07

765 Freedom Health PO Box 151348

Tampa FL 33684

800.401.2740 41212 8/21/09 www.freedomhealth.com

766 Palmer & Cay/Carswell Inc. PO Box 1286

Savannah, GA 31402

912.234.6621

767 HealthSCOPE Benefits PO Box 619055

Dallas TX 75261-9055

800.660.6212 71063 8/31/09

http://www.imala.com/

http://www.royalneighbors.com/

March 9, 2015 32

SC


CHANGE

NOTE

768 TPA Wisconsin Physicians Services 1717 W. Broadway St.

Madison, WI 53708

888.915.4158 SX162

769 FFS FEDEX Freightways PO Box 840

Harrison, AR 72602

800.874.4723 Was American Freightways, Inc.

770 Peoples Benefit Life Ins. PO Box 484

Valley Forge PA 19493

800.523.7900

771 Error in Assignment Duplicate Assignment; Use #D57

Was Connecticut General (CIGNA)

772 FFS Benefit Systems, Inc. PO Box 6001


800.842.3216

773 FFS Physicians Mutual Insurance Co. (Individual

Claims)

PO Box 2018

Omaha, NE 68103.2018

800.228.9100

402.633.1000

47027

59140

11.07.07

This is the same company as Seattle WA—

Neic. 59140

774 MA

RX

Molina Medicare Options Plus PO Box 22811

Long Beach CA 90801

800.665.1328 80840 9/18/09 www.molinamedicare.com

775 TPA First Choice Benefits Mgmt. PO Box 658

Beloit, WI 53512.0658

800.303.5770

776 PPO AFID (Association of Franchise and

Independent Distributors)

1 S. Limestone St. Ste. 301

Springfield OH 45502

866.766.9016 03.17.08 Paper claims only

777 PPO US Health And Life PO Box 37504

Oak Park MI 48237.0504

800.225.9674 38259 11.08.07 Automated Benefit Services is the TPA for

this insurance

778 MS American Continental Insurance Co. PO Box 2368

Brentwood TN 37024

615.377.1300

10.31.07 Plan J—updated from code D48

779 TPA WEB-TPA

(American Fidelity Assurance Company)

PO Box 99906

Grapevine TX 76099-9706

866.393.2872 75261 10/13/09 www.webtpas.com (parent company is Amwins

Group Inc.)

780 TPA Corporate Systems Administrators PO Box 4966

Johnson City, TN 37602.4966

800/275.2847 Re.activated at Medicaid’s request

781 TPA Medical Claims Management PO Box 12995


800.334.0609

704.525.1473

782 TPA Housing Benefit Plan PO Box 542077

Dallas, TX 75354.20777

800.937.2036

783 Dormant 6/08 Use code 940 for PHCS (Private Health Care

Systems.) Incorrect assignment.

784 SI Pacific Health Administrators PO Box 620123

Orlando, FL 32862.0123

800.776.6070

785 TPA The Harvest Insurance Co. PO Box 956003

Lake Mary, FL 32795.6003

800.253.0856

786 TPA ACS Benefit Services, Inc. PO Box 2000

Winston Salem NC 27102-2000

800.849.5370 72467 11/3/09

787 MS Pacificare Senior Supplement PO Box 6072

Cypress, CA 90630.0072

800.851.3802 95959

788 MS Transamerica Life Insurance Company

*(Monumental Life Insurance Company)

PO Box 3350

Cedar Rapids IA 52406-3350

800.854.0186 11/11/09 Both companies are members of the

Aegon Group and are one and the

same


http://www.webtpas.com/

March 9, 2015 33

SC


CHANGE

NOTE

789 MS FirstCommunity Health Plan, Inc. PO Box 382947

Birmingham, Al. 35238

800.734.7826

790 HMO MHNet Behavioral Health – (Medicare)

( Windsor Health Plan)

PO Box 7802

London KY 40742

866-992-5246 74289 12/17/09 www.mhnet.com

791 PPO UnitedHealth Integrated Services PO Box 30783


866.596.8447 39026 12/28/09 www.uhis.com

792 FFS Pioneer Life Insurance Co. of Illinois 304 N. Main St.

Rockford, IL 61105

800.552.2166

815.987.5000

793 MA

HMO Humana Gold Plus PO Box 14601

Lexington KY 40512-4601

800.457.4708 61101 1/5/10

794 FFS United Family Life Insurance Co. PO Box 2204

Atlanta, GA 30301

404.659.3300 91693

795 SI Regional Medical Administrators, Inc. PO Box 4128

Glen Raven, NC 27215.0901

800.711.1507

796 PPO LINECO 2000 Springer Drive

Lombard, IL 60148

800.323.7268 None 05.29.07

797 MA

PPO

Today’s Options

Universal American

PO Box 742528

Houston, TX 77274

866-422-5009 48055

1/5/10

798 PPO

Medcare International 12480 West Atlantic Blvd

Suite 2 Coral Springs FL 33071

Coral S

Coral Springs FL 33071

954.345.5650

11.20.07 [email protected]

799 LTC Genworth PO Box 10821

Clearwater, FL 33757-0821

POBox 8021 San Rafael, CA

94912-9974

800.876.4582 was GE Financial Assurance Co.

800 TPA NEBCO (Tenneco) PO Box 97

Scranton, PA 18504 0097

800 717.7562

801 PPO Imerica Life and Health Ins Co 304 Iverness Way South Ste 355

PO Box 3287

Englewood CO 80155

877.797.4877

4/17/09

802 Constitution Life Insurance Co. PO Box 130


800.789.6364

803 First Continental Life Insurance Co. PO Box 1911

Carmel, IN 46032

800.538.1235

804 PPO Piedmont Community Healthcare, Inc. PO Box 14408

Cincinnati, OH 45250.0408

800.400.7247 31441 04.24.07

805 PTNA (Penn Treaty Network America Ins.

Co.)

PO Box 130


800.635.7418

806 HMO Network Health Plan PO Box 568

Menasha, WI 54952

920.720.1300 39111 06.11.07

807 HMO Optima Health Plan c/o Lason, Inc PO Box 5028

Troy, MI 48007.5028

800.229.1199 54154 06.26.07

808 New Market Dimensions PO Box 4339

Houston, TX 77210

800.570.6745 65056

809 MC Inter Valley Health Plan 300 South Park, PO Box 6002

Pomona CA 91769-6002

800-251-8191 2/26/10 www.ivhp.com

810 PPO United Resource Network PO Box 30758


877.801.3507

March 9, 2015 34

SC


CHANGE

NOTE

811 Spartanburg Regional Healthcare System PO Box 1000

Lancaster, SC 29721

877.629.0001 41194 08.28.07 Re.activated at Spartanburg’s request.

812 TPA UMR PO Box 30541


800-826-9781 39026 2/26/10

813 Century Planners (The Millennium Centre) 9201 Watson Road, Suite 350

St. Louis, MO 63126.1509

800.776.2452

814 Healthcomp Administrators PO Box 45018

Fresno CA 93718

800.442.7247

815 MS Bankers Fidelity Life Insurance Company C/O USNow

PO Box 260040

Plano TX 75026

866.458.7499 n/a 4/7/10 Bflic.com

816 MA

HMO

Arcadian Member Care

Community Care/Arcadian Health Plan

PO Box 4946

Covina CA 91723

800.573.8597 77045 01.25.08 arcadianonline.arcadianhp.com

817 Priority Health 1231 E. Beltline NE

Grand Rapids MI 49525-4501

616.942.1221

800.446.5674

N/A 4/8/10 www.priorityhealth.com

818 Seafarers Health & Benefit Plan (SHBP) PO Box 380

Piney Point MD 20674

800.252.4674 N/A 4/8/10 www.seafarers.org

819 Tricare Overseas Program

PO Box 7985

Madison WI 53707-7985

608.301.2311 N/A 6/4/10 www.tricare.mil

820 TPA MMSI – Mayo Management Services Inc.

(also Mayo Clinic Health Solutions)

4001 41st Street West

Rochester NM 55901

800.635.6671 41154 8/11/10

821 HMO ODS Health Plan Advantage PO Box 4030

Portland OR 97208.4030

877.337.0650 13350 10.10.07

822 PPO Medical Mutual Insurance Company of Ohio PO Box 6018

Cleveland, OH 44101

800.258.2873

29076 2/5/09 www.medmutual.com

823 HMO Health Alliance Plan 2850 W Grand Blvd

Detroit MI 48202

800.422.4641

38224 10.30.07

824 RX Envison RX Options 21818 East Aurora Rd., Ste 201

Twinsburg OH 44087

800.361.4542 None www.envisionrx.com

825 MA

HMO

UnitedHealthcare Community Plan

(formerly Unison Advantage) 10/1/13 this plan

becomes Wellcare

PO Box 8207

Kingston NY 12402

800.600.9007 25175 3/15/11 www.uhccommunityplan.com

826 Wilse & Associates, Inc. 1005 Charles St, Tower 2, 9th Fl.

Baltimore, MD 21201

800.423.9791

410.547.0454

827 TPA J. Smith Lanier PO Box 72749

Newnan, GA 30271

888.295.4864

828 RX National Pharmaceutical Services PO Box 407

Boystown, NE 68017

800.546.5677

829 TPA Administrative Solutions PO Box 2490

Alpharetta, GA 30023

678.339.0211

830 TPA Contractors Employee Benefit Administrators

(CEBA)

9003 Waterford Center Blvd.

Austin, TX 78758

800.247.7724

831 TPA Corporate Benefit Solutions, Inc. PO Box 8215


888.604.9397

http://www.priorityhealth.com/

http://www.seafarers.org/

http://www.tricare.mil/

http://www.uhccommunityplan.com/

March 9, 2015 35

SC


CHANGE

NOTE

832 TPA Cameron and Associates 6100 Lake Forest Dr.

Atlanta, GA 30328

800.387.9919

833 PPO Mercy Health Plans PO Box 4568

Springfield MO 65808.4568

800.647.2240 08.13.07

834 PPO Definity Health (PPO) PO Box 69305

Harrisburg, PA 17106.9305

866.333.4648 64159

835 RX Managed Pharmacy Benefits 1100 North Lindberg

St. Louis, MO 63132

800.672.9540

836 PPO Humana Choice Care PPO PO Box 14610

Lexington KY 40512

866-427-7478 Name change to indicate “care” 7/28/09

837 Health Administration Services PO Box 6724208

Houston, TX 77267

800.865.5440

838 SI Shesfield, Olson & McQueen PO Box 16608

St. Paul, MN 55116

888.330.8408

839 Citizens Security Life Insurance Co. PO Box 436149

Louisville, KY 40253.6149

800.843.7752

502.224.2420

840 American Income Life Insurance Co. PO Box 2608

Waco, TX 76797

817.772.3050 60577

841 SI Watkins Associated Industries PO Box 1738

Atlanta, GA 30301

800.333.3841 58082

842 Gardner & White, Inc. PO Box 40948


317.257.9131

843 TPA Core Management Resources Group PO Box 840

Macon, GA 31202.0840

888.741.2673 www.coremrg.com

844 MA

PFFS

Prime Time Health Plan PO Box 6905

Canton OH 44706

800.617.7446

330.363.7460

N/A 9/8/10 www.primetimehealthplan.com

845 MA

HMO

Geisinger Health Plan Gold PO Box 8200

Danville, PA. 17821.8200

800.498.9731 75273

06.13.07

846 RX Script Care, Inc. 87 Interstate 10 North, Suite 100

Beaumont, TX 77707

800.280.7093

847 TPA Mahoney Benefits Administration PO Box 7260

Fort Lauderdale, FL 33338

800.280.7093

848 TPA Heritage Consultants PO Box 1730

Auburndale, FL 33823

800.282.2460 59230

849 TPA E.O.S. Health PO Box 27088

Tempe, AZ 85285

850 PPO Onenet PPO/MAPSI PO Box 934

Frederick, MD 21705.0934

800.342.3289 52149 07.02.07

851 MS BCBS of North Carolina State Health Plan PO Box 2291

Durham NC 27702

800.214.4844 10/14/10 www.shpnc.com

852 Builders Mutual Insurance Company PO Box 150006

Raleigh NC 27624-0006

800.809.4861 N/A 10/26/10 www.buildersmutual.com

worker compensation plan

853 Compsych Corp. PO Box 8379

Chicago, IL 60680

877.595.5282

http://www.coremrg.com/

http://www.primetimehealthplan.com/

http://www.buildersmutual.com/

March 9, 2015 36

SC


CHANGE

NOTE

854 SI Boyd Care (Boyd Brothers Transportation) PO Box 70

Clayton, AL 36016

334.775.1284

855 TPA University Health Plans PO Box 830926, Dept. 003


877.878.0914

856 Transamerica Occidental Life PO Box 2101, Terminal Annex

Los Angeles, CA 90051

213.742.2111 12T76

TH128

857 TPA Corporate Benefit Services, Inc. PO Box 12953

Charlotte, NC 28220

704.373.0447 56116

858 DEN DentaQuest PO Box 2136

Columbia SC 29202

888.307.6553 52040 10/27/10 Medicaid dental program

www.dentaquest.com

859 New England Group Trust PO Box 30466

Tampa, FL 33630

800.654.1731 66893

860 Managed Health Network 5100 Goldleaf Circle, Suite 300

Los Angeles, CA 90056

800.777.9355

861 SI Superior Essex PO Box 724907

Atlanta, GA 31139

877.291.7920

862 TPA Performax 300 Corporate Parkway

Amherst, NY 11226

877.777.6076

863 TPA Insurance Administration Corp. (IAC) PO Box 21456

Eagan MN 55121

866.416.2260 5/15/09 Claim address changed from PO Box 828,

Parkridge IL 60068.0828

864 TPA GE Group Administrators PO Box 3005

Agawam, MA 01001

888.255.8961

865 DEN Securian Dental Plans PO Box 9385

Minneapolis, MN 55440-9385

800.234.9009 93742 11/19/10 www.securiandental.com

866 Olympic Health Management PO Box 5348


360.734.9888

867 State of NC Comp. Health Benefit

NC State Employees Processing Unit

PO Box 30025

Durham, NC 27702

919.489.7431

868 FFS Kansas City Life Insurance Co. PO Box 219325


800.874.5254 65110

869 TPA Employee Benefit Management Services PO Box 21367

Billings, MT 59102

800.777.3575

870 HMO Foundation Health(HMO) PO Box 453219

Sunrise, FL 33345

800.442.5501

871 HMO United Behavioral Health (UBH)((HMO) PO Box 169053.RT.20003

Duluth, MN 55816

800.877.6003

404.846.7500

see also #930 PPO

872 Dormant 6/08 Was John Deere Health Plan (HMO)

UnitedHealthcare purchased John Deere HMO

873 Medco Health PO Box 8190

Madison, WI 53708.8190

800.221.7006

874 Health Net PO Box 14700

Lexington, KY 40512

888.747.7823 06108

875 American Sentinel PO Box 61140

Harrisburg, PA 17106.1140

800.692.7338

http://www.dentaquest.com/

March 9, 2015 37

SC


CHANGE

NOTE

876 CIGNA Healthcare (Healthsource SC Inc) PO Box 28087

Raleigh, NC 28611

800.849.9000 06119

877 Pre-Existing Condition Insurance Plan (PCIP) PO Box 300

Independence MO 64051-0300

800.220.7898 57254 www.pciplan.com

878 TPA HRM Claim Management PO Box 4022

Kalamazoo, MI 49003.4022

800.253.0966 Parent: Health Risk Mgt.

879 HMO (formerlyWellPath Select(HMO)

c/o Coventry Health Care

PO Box 7102

London, KY 40702

800.735.7284 25133 Emdeon NEIC change 1/20/10 from 25129

880 PPO Optimum Health Partners(PPO) PO Box 2243


864.213.4992 St. Francis Hospital

881 PPO Behavioral Health Systems PO Box 830724

Birmingham AL 35283-0724

800.245.1150

205.879.1150

63100 12/6/10 www.behavioralhealthsystems.com

882 MA Connecticare

PO Box 4000

Farmington CT 06034

877 224-8230

78375

3/1/11 www.connecticare.com

883 HMO Select Health of South Carolina, Inc (HMO) 7410 Northside Dr., Ste. 208


95458 use #637 for Medicaid HMO

884 HMO Health First Health Plans PO Box 565001

Rockledge, FL 32956.5001

800.716.7737 95019

885 FFS John Alden Life Insurance PO Box 528060D

Miami, FL 33152

800.328.4316

305.715.2699

41099

886 TPA Planned Administrators, Inc. (PAI) PO Box 6702

Columbia, SC 29260

888.645.6410

803.754.0041

37287 BCBS uses Preferred Blue network

887 PPO CNIC Health Solutions PO Box 3559

Englewood, CO 80155

800.426.7453 37227 .

888 Southeastern Benefit Plans, Inc. 335 Archdale Drive


889 FFS Group Insurance Administration 850 W. Jackson Blvd.

Chicago, IL 60607

800.621.0683

890 HMO PARTNERS National Health Plan of NC, Inc

(HMO)

PO Box 24907

Winston.Salem, NC 27114.4907

800.942.5695 95300

891 HMO Optimum Choice of the Carolinas, Inc (HMO) 4 Taft Court

Rockville, MD 20850

800.343.8205 95312

892 HMO Independent Health PO Box 9066

Buffalo, NY 14231

800.247.1466 95308 See also #D44

893 Keystone Health Plan East (Medicaid HMO) PO Box 8339

Philadelphia PA 19101

800.227.3116 SX055

894 HMO Amerihealth Mercy Health Plan

(Medicaid HMO for PA)

PO Box 7118

London, KY 40742

888.991.7200 22248

895 FFS Continental Life Ins. of Brentwood, TN PO Box 1188

Brentwood, TN 37024

615.377.1300 68500

896 FFS OptiMed Health Plan 902 Clint Moore Rd., Suite 100

Boca Raton, FL 33487

800.482.8770

897 TPA Southern Benefit Admin. 5307 Virginia Beach, Suite 102

Norfolk, VA 53502

http://www.connecticare.com/

March 9, 2015 38

SC


CHANGE

NOTE

898 Association & Society Insurance Corp. PO Box 2510

Rockville, MD 20847

800.638.2610 TRICARE Supplemental

899 HMO Aetna Health Plans of South Carolina, Inc

(HMO)

PO Box 27190

Greensboro, NC 27402.6190

800.459.1466 95343 600524 see also #100; #917

900 SI Kohler Company 444 Highland Drive

Kohler, WI 53044.1515

414.457.4441 Employee Benefits

901 HMO Dental Care Plus 100 Crowne Point Place

Cincinnati OH 45241

800.367.9466 N/A 3/3/11 www.dentalcareplus.com

902 HMO Blue Care Network of MI POB 68710

Grand Rapid, MI 49516

800.658.8878 04.31.07 Was M-Care

903 HMO Careplus Health Plan PO Box 31286

Tampa, Fl 33631.3286

866.313.7587 95092 04.24.07

904 PPO Best Choice Plus Health Plan PO Box 21128

Fort Lauderdale, FL 33335

800.867.4446 2.27.06 37314

905 Gerber Life Medicare Supplement PO Box 2271

Omaha NE 68103

877.656.5424 71412 3/3/11

906 Dormant

907 FFS Celtic Life Insurance Co. PO Box 46337

Madison, WI 53744

800.766.2525

908 TPA NRECA c/o Berkeley Coop. PO Box 1234

Moncks Corner, SC 29461

843.752.5454

909 TPA Preferred Health Alliance & the Kinon Group

Aka (21st Century Benefit Plans)

PO Box 382048

Birmingham AL 35238

205.969.1155

800.722.8477

12/30/08 Former information: Preferred Health Alliance

&

Corporate Benefit Consultants

300 Corporate Parkway, Suite 3

Birmingham, AL 35242 910 Gallagher Bassett Benefit Administrators 8355 N.W. 53rd St., #215

Miami, FL 33166

800.659.5005

911 Community Health Partners PO Box 5787


888.962.8437

912 PPO Wells Fargo TPA. NC Offices PO Box 2857

Fayetteville NC 28302

800.337.6288 37272 05.08.08

913 Florida Hospital Helathcare System and

Sunbelt Medical Management

PO Box 536847

Orlando FL 32853-6847

800.741.4810 59321 3/11/11

914 National Teachers Assocates Life Insurance

Company

(formerly National Life Insurance Company)

PO Box 2369

Addison TX 75001

888-671-6771 5/16/11 www.ntalife.com

915 PPO Managed Health Resources PO Box 30742

Charlotte, NC 28230

704.398.6180

916 MHealth PO Box 742567

Houston TX 77274

888-642-5040 TH092 www.mhealthbenefits.org

Fully owned subsidiary of Memorial Hermann

917 PPO Aetna Health Plans(PPO)

(Aetna US Healthcare)

1010 Charlotte Plaza

Charlotte, NC 28244

see also #100; #899

918 PPO Affordable Medical Networks/ Healthcare

COMPARE Corp.(PPO)

3200 Highland Avenue

Downers Grove, IL 60515.1223

630.737.7900 68195 First Health Life and Health Ins.

http://www.mhealthbenefits.org/

March 9, 2015 39

SC


CHANGE

NOTE

919 PPO American Health Group, Inc.(PPO) PO Box 1500

Maumee, OH 43537

800.861.5770

920 PPO Healthsmart Preferred Care(PPO) PO Box 53010

Lubbock, TX 79453.3010

806.473.2500 75250 PPO network for Icon #371

921 PPO Beech Street(PPO) 173 Technology St.

Irvine, CA 92660.2526

95377

922 HMO BlueChoice Healthplan of S.C.

(My Choice Advantage) EPO

PO Box 6170


800.868.2528

803.786.8476

95741 7/8/14 Re.activated 4/25/06 updated 7/8/14

Non.Medicare HMO

923 HMO United Healthcare Community Plan

(Medicaid Plan)

PO Box 5220

Kingston NY 12402

800-690-1606 95378 5/16/11 Uhccommunityplan.com

924 PPO CAPP Care(PPO) West Tower; 4000 McArthur

Blvd., #10,000; Newport Beach,

CA 92660

925 PPO CIGNA Healthcare of SC/CIGNA Corp.(PPO) 11121 Carmel Commons Blvd.

#300 Charlotte, NC 28226

62308 see also #134

926 PPO CNA/Private Healthcare Systems/CNA

Insurance(PPO)

2302 Parklake Dr., NE

Atlanta, GA 30345

927 United Healthcare Heritage Plus UHC of River Valley

PO Box 5230

Kingston NY 10242-5230

800.224.6602 95378 6/1/11 Uhcrivervalley.com

This product and RiverValley are the same

928 Cook Insurance PO Box 1029

Bloomington IN 47402

800.593.2080 35149 6/1/11 Self funded employer insurance

929 FFS National Health Insurance Co. PO Box 619999; Dallas/

Ft. Worth Airport, TX

75261.9999

800.237.1900 82538

930 Sentry Life Insurance Company PO Box 8025

Stevens Point WI 54481

800.426.7234 8/11/11 www.sentry.com

School accident insurance policy

931 PPO Good Samaritan Program(PPO) P.O Box 279

Beachgrove, IN 46140

317.894.2000

932 MS Manhattan Insurance Group

(Family Life Insurance)

PO Box 925309

Houston TX 77292-5309

800.669.9030 8/23/11 www.manhattanlife.com

933 PPO OSF Healthplans PO Box 1229

Peoria IL 61654.1229

800.673.5222

62171 12.17.07 www.osfhealthplans.com

934 PPO MVP Select Care, Inc. PO Box 1434

Schenetady, NY 12301.1434

800.229.5851

935 PPO Medical Control, Inc.(PPO) 13 W. Park Square, Suite D

Marietta, GA 30060

75229

936 PPO Key Benefits.TransChoice Plus PO Box 1279

Fort Mill SC 29716.1279

800.591.6764 37284 04.30.08 Limited benefit and hospital indemnity

937 MVP Health Care (formerly Preferred Care) 259 Monroe Ave

Rochester NY 14607

800.950.3224 SX089 5/26/09 Name change only as of 4/09

938 PPO Preferred Health Network(PPO) PO Box 60308

Los Angeles, CA 90060.0308

310.983.1616

939 PPO Premier Health Systems, Inc.

PO Box 1640


90440 4/29/09 Updated information

http://www.sentry.com/

March 9, 2015 40

SC


CHANGE

NOTE

940 PPO PHCS (Private Health Care Systems) PO Box 2914

Des Plaines, IL 60017.2914

800.531.7662 None 06.15.07 Incorrectly assigned as 783

941 PPO ANTARES/EHP PO Box 477911

Broadview Htgs. OH 44147.9998

800.451.7929 34192 03.03.08 www.chnetwrok.com

942 PPO Principal Life Insurance Company(PPO) PO Box 39710

Colorado Springs, CO

80949.2910

800.331.9443 61271 aka Principal Financial Group (wasPrincipal

Mutual Ins.)

943 PPO Liberty Mutual Life Insurance

HRMP Medical Conversion Claims

5 Hutchinson Dr

Danvers, MA 01923

888.999.4767

See also #959

944 PPO CCN(PPO) 9313 Medical Plaza Dr., Ste. 203;

Box 12, Charleston, SC 29406

800.247.2898 5251 Viewridge Court

San Diego, CA 92123

945 Senior Health Insurance Company of

Pennsylvania (SHIP)

PO Box 64913

St Paul MN 55164

877.450.5824 9/7/11 www.shipltc.com

LTC claims

946 PPO PO Box 1377

Thomasville GA 31799

888.426.1937 03.03.08 Paper Claims only

Division of First Medical Network

947 PPO United Healthcare of NC(PPO) PO Box 26303


800.999.1147 67726 see also 113, 715, 881, 950

948 FFS Philadelphia American Life Insurance

Company

PO Box 2465

Houston, TX 77252

67784 800.333.9413/713.871.4990

Phone numbers incorrect 5/20/09

949 PPO Humana Medical Plan Inc. for American Family PO Box 14601

Louisville, KY 40201.3127

800.448.6262 39634

950 PPO ProAmerica Managed Care(PPO)

(United Healthcare Corp.)

PO Box 202008

Fort Worth, TX 76006.8008

see also #113, #715, #881, #947

951 American Group Administrators 101 Convention Center Dr Suite

200

Las Vegas, NV 89109

800.842.4742

952 Stark Truss Co., Inc; c/o Chandler Group PO Box 2080C

Stow, OH 44224

800.456.4002 American Benefits Management TPA for Stark

953 PPO USA Healthcare Organization(PPO) aka H&W

Network/USA Managed Care

7301 N. 16th St., Ste. 201

Phoenix, AZ 85020

800.872.3860

602.371.3860

954 PPO MultiPlan(PPO) 115 5th Avenue

New York, NY 10003.1004

800.546.3887

955 PPO Design Savers Plan 2814 Spring Rd, Suite 122

Atlanta, GA 30339

800.616.5709

956 PPO MedCost Preferred(PPO)

(NC Baptist Hosp/Carolina Healthcare)

1399 Ashleybrook Lane, Ste. 100,


957 PPO WellPath Preferred PO Box 7102

London, KY 40702

800.935.7284 25129

958 SI ITPE.NMU/MEBA Health & Welfare Fund 835 East 65th Street

Savannah, GA 31405

912.352.7169

959 WC Liberty Mutual Insurance Company

2000 Center Point Dr., #2190, Cola. 29210

PO Box 25333, Charlotte, NC

28229

PO Box 31204, Tampa. FL 33631

800.532.7706

800.922.3305

11123 Workers Comp. Claims

See also #943

960 PPO HEALTH EOS PO Box 6090

De Pere, WI 54115.6090

800.435.5694 36331

961 PPO MHN (Managed Health Network)

Clark County Firefighters

PO Box 27018

Las Vegas, NV 89126

800.458.4642

http://www.shipltc.com/

March 9, 2015 41

SC


CHANGE

NOTE

962 Vicare Plus PO Box 1710

Suffolk, VA 23439

877.934.4403

963 UnitedHealthcare Oxford PO Box 708s

Bridgeport CT 06111

888.201.4111 06111 3/20/12 Name change from Oxford Health Plans

964 RX Pharmaceutical Care Network 9343 Tech Center Drive

Sacramento, CA 95826

800.777.0074

965 TPA Professional Benefit Administrators, Inc.

(PBA)

PO Box 4687

Oakbrook, IL 60522.4687

630.655.3755 36331

966 TPA Capitol Administrators of the Southeast PO Box 346


888.650.6566

967 Underwriters Safety & Claims PO Box 23507


800.678.1536

968 TPA American Benefit Administrative Services PO Box 0928

Brookfield, WI 53008

630.416.1111 37225

969 SI WHP Health Initiative (Walgreen’s Health

Plan)

2275 Half Day Road

Bannockburn, IL 60015

800.207.2568

970 PPO Consolidated Workers Association PO Box 2647

Chino Hills CA 91709

800.919.5514 N 03.31.08 www.cwabenefits.com

Paper Claims Only

971 TPA Atlanta Administrator 135 Beaver Street

Waltham, MA 02452

800.548.1256

972 TPA Administration System Research Corp. (ASR) PO Box 6392

Grand Rapids, MI 49512

800.968.2449 38265

973 TPA Cambridge Integrated Services Group Inc. PO Box 1687

Grand Rapids, MI 49501

800.766.9780

974 TPA Commerce Benefits Group PO Box 900

Elyria, OH 44036

800.223.9941 34181

975 TPA National Medical Health Card PO Box 1170

Fort Washington, NY 11050

800.645.3332

976 TPA Paragon Benefits, Inc. PO Box 12288

Columbus, GA 31917

706.277.6710

977 FFS Compass Rose Health Plan PO Box 6430

Annapolis MD 21401

877.531.1159 50946 9/16/11 www.compassrosebenefits.com

978 SI Leggett & Platt PO Box 7687

High Point, NC 27264

417.358.8131 75279

979 TPA Medical Reimbursement of America 113 Seaboard Lane, Suite 200

Franklin TN 37067

615.963.3826 62177

980 TPA Benefit Support, Inc PO Box 2977

Gainesville, GA 30503

800.777.4782

770.532.2690

981 RX Argus Health Systems PO Box 419019

Kansas City MO 64141

800.522.7487 10/6/11 www.argushealth.com

982 PPO Office of Group Benefits - State of Louisiana PO Box 44036

Baton Rouge, LA 70804.4036

800.215.1093 72087

983 TPA International Brotherhood of Electrical

Workers

3901 E. Winslow Avenue

Phoenix, AZ 85040

602.234.0497 Venus Administrators

http://www.cwabenefits.com/

http://www.argushealth.com/

March 9, 2015 42

SC


CHANGE

NOTE

984 Homeland Healthcare

(supplemental health insurance)

PO Box 3726

Seattle WA 98124

800.493.4240 59140 www.homelandhealthcare.com

985 TPA Benesight PO Box 340

Pueblo, CO 81002

800.562.7079 87265

986 TPA Common Wealth Benefit Administrators 115 Hanover Street

Ashland, VA 23005

800.526.1677

987 FFS Bankers Fidelity Life Insurance PO Box 190750

Atlanta, GA 31119

800.241.1439

404.266.5500

61239

988 FFS Mid West National Life Insurance Co. PO Box 98216

Dallas, TX 75380

800.733.1110 66087

989 Univera Healthcare PO Box 23000

Rochester, NY 14692

877.242.9464

990 TPA Southern Group Administrators, Inc. 200 South Marshall Street


800.334.8159 56131

991 TPA West Port Benefits PO Box 66743

St. Louis, MO 63166

888.306.5299

992 TPA Chesterfield Resources, Inc. PO Box 1884

Akron, OH 44309

800.321.0935

993 SI MPI International Inc. PO Box 81913

Rochester, MI 48308.1913

248.853.9010

994 RX United Provider Services PO Box 820277

Ft. Worth, TX 76182

800.519.8374

995 RX MEDIMPACT 10680 Treena Street

San Diego, CA 92131

800.788.2949

996 TPA J.F. Molloy & Associates PO Box 68947


800.331.3287 61271

997 MS Genworth Financial PO Box 10821

Clearwater, FL 33757

877.825.9337 No

998 DEN Canada Life Assurance Co., The PO Box 105025

Atlanta, GA 30348

800.333.2542

– Ind.

800.554.4026

. Group

999 HMO CIGNA Healthcare of SC(HMO)

(Healthsource SC Inc.)

146 Fairchild Drive


843.884.4063 62308

A01 SI Thritvent Financial for Lutherans 4321 N. Ballard Rd.

Appleton, WI 54919

800.847.4835 Was Aid Association for Lutherans (Name

change)

A02 Alternative Benefits Plans, Inc. 2920 Brandywine Rd. Ste. 106

Atlanta, GA 30341

800.241.7319

A03 TPA Starmark PO Box 777

Lake Forest, IL 60045

800.782.7907 61425

A04 RX Consultec Prescription Benefits Mgt. 9040 Roswell Rd, Ste. 700


800.365.4944

A05 American Public Life Ins. Co. P. O. Box 925

Jackson, MS 39205

800.256.8606 60801 www.ampublic.com

A06 FFS Colonial Penn Franklin Life Insurance

Company

399 Market St.

Philadelphia, PA 19181

800.523.4000 62065

March 9, 2015 43

SC


CHANGE

NOTE

A07 FFS Continental Life Insurance Company of SC PO Box 6138

Columbia, SC 29260

803.782.4947 62480

A08 Independence American Insurance Co. PO Box 21456

Eagon MN 55121

866.429.0608 56162 www.independenceamerican.com

A09 RX RX America 369 Billy Mitchell Rd.


800.770.8014

A10 RX Ameriscript 4301 Darrow Rd. Ste. 4200

Stow, OH 44224

800.681.6912

A11 Preferred Administrators P.O. Box 18263

Tampa, FL 33679.8263

877.276.7198

A12 Mountain Claims Management PO Box 1008

Fruitland, ID 83616

866.952.7979

A13 Dormant

A14 RX EB RX (Pharmacy Services Support Center) 2045 Midway Dr.

Twinsburg, OH 44087

800.800.7153

A15 RX Managed Prescriptions Services (MPS) PO Box 66979

St. Louis, MO 63166.6922

800.759.6959

A16 FCE Benefit Administrator 445 Recoleta, Ste. 100


800.899.9355

A17 TPA Nova Healthcare Administrators PO Box 308

Grand Island, NY 14072.0308

800.333.3195 16644

A18 MSH Mobility Benefits PO Box 77

Beebe Plain, VT 05823

888.842.1530 04.16.07 International company – claims hard copy only

A19 PPO Island Group Administration, Inc. 3 Toilsome Lane

East Hampton, NY 11937

800.926.2306 05.11.07

A20 TPA Professional Claims Mgt. PO Box 35276

Canton, OH 44735

800.325.8424 37242

A21 PPO PC Health Plan Admin. PO Box 1377

Thomasville GA 31799

888.426.1937 04.07.08 Paper Claims Only for now

www.physicianscaptives.com

A22 TPA Piedmont Administrators PO Box 78030


800.852.7040

A23 RX Serve-U Prescription PO Box 23237.0237

Milwaukee, WI 53233

800.759.3203

A24 RX Well Point Pro-Serve PO Box 9081

Oxnard, CA 93031.9081

800.962.7378

A25 RX Benescript PO Box 921229

Norcross, GA 30092

A26 Markel Smart STM (Short Term Medical) PO Box 610190

Dallas Tx 75261-0190

800.279.2290 39182 10/17/11 www.markelsmart.com

A27 Healthcare Support 25 Columbia Heights

Brooklyn Heights, NY 11201.2483

800.554.4022

A28 FFS Shenandoah Life Insurance PO Box 12847

Roanoke, VA 24029

800.848.5433

540.985.4400

68845

http://www.independenceamerican.com/

http://www.markelsmart.com/

March 9, 2015 44

SC


CHANGE

NOTE

A29 TPA Meritain Health PO Box 853921

Richardson, TX 75085.3921

800.776.2452 64157

A30 RMSCO Inc (Asplundh Tree Experts Co) PO Box 678

Liverpool, NY 13088.0678

877.204.7086 16117

A31 Unity Health Insurance PO Box 610

Sauk City, WI 53583.1374

800.362.3308

A32 SI Magellen Behavioral Health PO Box 1659

Maryland Heights, MO 63043

800.359.2422 01260

A33 Alliant Health Plans, Inc. PO Box 3708

Corpus Christi, TX 78463

800.811.4793 58234

A34 Geico Imdeminty Company

(liability insurance)

1 Geico Center

Macon GA 31296

800.841.8842 10/16/11 www.geico.com

A35 Buncombe Co. Medical Society Corp

Employee Benefit Trust Health Plan

PO Box 2899

Asheville, NC 28802

828.254.2339

A34 Geico Imdeminty Company


1 Geico Center

Macon GA 31296

800.841.8842 10/16/11 www.geico.com

A36 State Farm


PO Box 106145

Atlanta GA 30348-6145

866.432.7565 10/16/11

A37 PPO United Healthcare of Ohio aka United

Behavioral Systems(PPO)

PO Box 182286, Rt. 210052

Columbus, OH 43218.2286

800.504.4853

A38 United Health Care of N.C. PO Box 2604


800.999.1147

A39 Complete Benefits Solutions PO Box 3649


866.270.2316

A40 TPA Strategic Resource Co. PO Box 23759


803.736.6463

A41 Claims Management Services

(Division of TCS)

PO Box 10888

Greenbay, WI 64307.0888

800.472.7130

414.497.1589

39141 See B40

A42 FFS Primerica Life Insurance 3120 Breckinridge Blvd.

Duluth, GA 30199

800.257.4725

404.381.1000

65919

A43 Farm Bureau Mutual Insurance Co.


207 Shirt Street/PO Box 758

Kingstree SC 29556

866.354.9616

A44 Global Medical Management, Inc 7901 SW 36th Street, Suite 100

Davie, FL 33328

954.370.6404

A45 FFS Inteq Group PO Box 80159

Dallas, TX 75382.0159

800.324.2200

A46 FFS Standard Insurance Co. PO Box 209

Portland, OR 97207.0209

503.321.6655 69019

A47 The Hartford


PO Box 31001

Tampa FL 33631

10/17/11

A48 SC Farm Bureau Insurance Company


PO Box 657

Georgetown SC 29442

843.527.1131 10/17/11

A49 Arizona Foundation for Medical Care PO Box 2909

Phoenix, AZ 85062.2909

602.231.8855

March 9, 2015 45

SC


CHANGE

NOTE

A50 Progressive

(limited liability insurance)

1088 Vista Park Dr. Suite A

Forest,VA 24551

434-386-2717

10/17/11 www.progressive.com

A51 MS Humana Medicare Supplement Plan PO Box 14601

Lexington KY 40512

800.866.0581 61101 10/26/11

A52 Nationwide Speciality Health Claims

PO Box 420

Springfield, MA 01101

800-517-4791

10/27/11

A53 US Administrators Claims PO Box 2908

Kennesaw GA 30156

865.481.7969 10/31/11 Limited liability insurance

A54 PPO Century Healthcare PO Box 2256

Grapevine, TX 76099

888.444.1995 30018

06.26.07

A55 Auto Owners Insurance PO Box 27125

Greenville SC 29616-2125


A56 QBE Specialty Insurance PO Box 212128

Columbia SC 29221


A57 ESIS AGL Southeast Hub


PO Box 5128

Scranton PA 18505-0560


www.esis.com

A58 Dairyland Insurance Company


PO Box 8041

Stevens Point WI 54481

919.751.7828 11/4/11

A59 Access General Insurance Company


PO Box 105143

Atlanta GA 30348

800.817.9744 11/4/11 www.accessgeneral.com

A60 MCR

HMO

University Healthcare 5100 Commerce Crossings Dr.

Louisville KY 40229-2128

800.578.0603 11/4/11

A61 SummaCare Health Plan PO Box 3620

Akron, OH 74389.3628

888.996.8481 95202

A62 American Medical and Life Insurance (AMLI) PO Box 1353

Chicago IL 60690

888.264.1512 46004 11/10/11 www.usamli.com

A63 Universal North America (Liability Insurance) PO Box 648

Battle Creek MI 49016

866.999.0898 N/A 11/23/11 Uihna.com

A64 PPO NTCA (National Telecommunications

Cooperative Association)

One West Pack Square, Ste 600

Asheville NC 28801-3459

828.281.9000 52103 12/1/11 www.ntca.com

This is a Multiplan PPO

A65 RX DataRx 5920 Odelle St

Cummings GA 30040

877.823.1273 n/a Data-rx.com

A66 Prairie States Enterprises, Inc. PO Box 23

Sheboygan WI 53082-0023

800.815.7020 36373 12/9/11 www.prairieontheweb.com

A67 TPA HealthScope Benefits PO Box 99005

Lubbock TX 79490-9005

800.967.6831 71063 www.healthscopebenefits.com

A68 Universal North America


PO Box 648

Battle Creek MI 49016

866.999.0898 N/A 1/17/12 www.universalnorthamerica.com

A69 Omni Insurance Co.


PO Box 105019

Atlanta GA 30348

800.727.6664 N/A 1/17/12 www.omni-insurance.com

A70 Optum Health

(behavioral health)

PO Box 30757


866.214.6829 87726 1/17/12 www.unitedhealthgroup.com

A71 Carolina Behavioral Health Alliance PO Box 571137

Winston Salem NC 27157-1137

800.475.7900 N/A 1/26/12 www.cbhallc.com

http://www.progressive.com/

http://www.esis.com/

http://www.accessgeneral.com/

http://www.usamli.com/

http://www.ntca.com/

http://www.healthscopebenefits.com/

http://www.universalnorthamerica.com/

http://www.omni-insurance.com/

http://www.unitedhealthgroup.com/

March 9, 2015 46

SC


CHANGE

NOTE

A72 SI Babb, Inc. 850 Ridge Ave.

Pittsburgh, PA 15212

800.245.6102

A73 Claims Technology Inc. 100 Court Ave. Ste. 306

Des Moines, Iowa 50309

800.245.8813

A74 First Carolina Care, Inc. 2500 Corporate Dr; PO Box

381686


800.811.3298 56196

A75 TPA Health Cost Solutions PO Box 1439

Hendersonville, TN 37077

888.229.5020 was Lifecare Centers of America

A76 Tower Life Insurance Company 310 S. Mary Street


800.660.6077 69493

A77 Sisco PO Box 389

Duduque, IA 52004

800.457.4726

A78 TPA Highway to Health (HTH) PO Box 968

Horsham, PA 19044

888.350.2002 54763

A79 TPA Health Special Risk 4001 N. Josey Lane

Carrollton, TX 75007

972.492.6474

A80 Total Script 10901 West 120th Ave. Ste. 110

Broomfield, CO 80021

800.752.2211

A81 TPA Benesys P.O. Box 90082

Lubbock, TX 79402

337.234.1789 37248

A82 United Healthcare Indemnity PO Box 740801


800.848.8406

A83 TPA Group Resources, Inc. 5161 Brook Hollow Pky., Suite

200, Norcross, GA 30093

404.242.7776

A84 HCC Life Insurance Company PO Box 863


866.400.7102 92711 1/26/12 Short term medical insurance

A85 QualChoice Po Box 25610

Little Rock AR 7221-9914

800.235.7111 35174 2/23/12 www.qualchoice.com

A86 Benefit Management Company PO Box 269000

Weston, FL 33326.9000

800.262.9175

954.384.1000

A87 MA SouthEast Community Care (Arcadian Health) PPO Box 4946

Covina CA 91723

800.573.8597 N/A 2/21/12 www.southeastcommunitycare.com

A88 MA WindsorSterling PO Box 269003

Plano TX 75026-9003

888.858.8551 67829 2/21/12 www.windsorsterlingplans.com

A89 MA UCare 500 Sinson Boulevard NE


3/8/12 N/A www.ucare.org

A90 Employee Benefit Claims, Inc. 820 Parish Street


800.922.4966

312.696.3660

A91 States General Life Ins Co. 115 West 7th St, Suite 1200


800.782.8375 65978

A92 MS Provident American Life & Health Ins PO Box 29158

Shawnee Mission, KS 66201.915

800.753.5133

Re.activated 9/06

A93 American College of Surgeons (ACS Ins.

Program)

PO Box 2522


800.433.1672

http://www.windsorsterlingplans.com/

March 9, 2015 47

SC


CHANGE

NOTE

A94 Forethought Life Insurance Company

(Medicare Supplement)

PO Box 981721

El Paso TX 79998

877.492.5870 N/A www.forethought.com

A95 Nationwide Insurance

(Liability Insurance)

One Nationwide Gateway, Dept

5582, Des Moines IO 50931

800.421.3535 3/15/12 www.nationwide.com

A96 SI Hamrick’s, Inc. Employee Benefit Plan 742 Peachoid Road

Gaffney, SC 29340

803.487.7505,

x517

A97 Employer Plan Services, Inc. 2180 North Loop West, Ste. 400

Houston TX 77018

800.447.6588

A98 Corporate Benefit Services of America, Inc. PO Box 738

Hopkins, MN 55343

800.765.4224 41124

A99 Cherokee Insurance PO Box 853925


800.201.0450 N/A 3/20/12 cherokee.usinsuranceonline.com

B01 Health Partners PO Box 1289

Minneapolis MN 55440.1289

888.922.2313 12X51 03.26.08 Placed back in active status

NEIC added 2/22/10

B02 Life Insurance Company of Alabama PO Box 349

Gadsden AL 35902

800.226.2371 N/A 3/20/12 www.lifeofalabama.com

B03 Chesapeake Life Insurance These codes previously inactive were not per

Rebecca Clark 3/23/12

B04 PPO Cariten Healthcare PO Box 22987

Knoxville, TN 37933

800.284.0042 62073

B05 Focus Healthcare Management, Inc. 720 Cool Springs Blvd.

Franklin, TN 37067

615.778.4000

B06 SouthCare Healthcare Preferred 1100 Circle 75 Parkway, Suite

1400

Atlanta, GA 30339

800.470.2004

678.202.2100

B07 MS Magnacare PO Box 1001

Garden City, NY 11530

516.489.3644 11303 1/15/14 www.magnacare.com

B08 AmFirst Insurance Company PO Box 16708

Jackson MS 93236

888.888.2519 N/A 3/30/12 www.morganwhite.com

B09 PPO Dearborn National

(Dental)

PO BOX 23060

Belleville IL 62223

800.271.7987 DNOA1 3/30/12

B10 TPA

PPO

Trident Plan Administrators 5045 N.12th St., Suite A

Phoenix, AZ 85014

800.362.5894

B11 PPO CBCA Administrators, Inc. PO Box 1272


888.446.5710 55438 4/29/09 www.cbca.com

Claims address & telephone number updated

B12 John Hancock Mutual Life Ins. PO Box 111

Boston MA 02117

Boston

800.732.5543

B13 Do not assign per Rebecca this already has a

payor

B14 TPA A.C.S. Consulting Services, Inc. 8025 N. Point Blvd.


919.759.2013

B15 Hillcrest Benefit Administrators P.O. Box 1516

Mt. Dora, Fl 32756

800.743.9264

B16 Partner RX Management P.O. Box 35007

Phoenix, AZ. 85069

800.659.4112

http://www.forethought.com/

http://www.nationwide.com/

http://www.magnacare.com/

http://www.morganwhite.com/

http://www.cbca.com/

March 9, 2015 48

SC


CHANGE

NOTE

B17 Ultra Benefits P.O. Box 763

Westboro, MA 01581

866.858.7223

B18 Lumenos P.O. Box 69309

Harrisburg, PA 17106

877.495.8478

B19 DENTAL Renaissance Dental PO Box 17250


888.358.9484 RLHA1 www.renaissancedental.com

B20 FMH Benefit Services, Inc. P.O. Box 25946


800.990.9058

B21 Pioneer Health P.O. Box 6600

Holyoke, MA 01041

800.423.4586

B22 PPO Southern Health Services P.O. Box 7704

London, KY 40742

800.627.4872

888.975.9557

25128 Updated

03.26.08

Coventry Health Care

B23 Lincoln Financial Group PO Box 614008

Orlando FL 32861

800.423.2765 N/A 4/19/12 www.lfg.com

B24 Emblem Health Co.

P.O. Box 3000

New York NY 10116-3000

212-501-4444

13551

www.emblemhealth.com

B25 SI Health & Welfare Fund – Local 218 PO Box 115027

Atlanta, GA 30310

404.755.5665

404.755.3310

B26 SI IMSCO Health Plan PO Box 697

Buckeystown, MD 21717.0697

800.944.2833

B27 PPO HealthFirst Preferred(PPO)

(Greenville Hosp. System)

255 Enterprise Blvd., Ste. 200

Greenville, Sc 29615

864.455.1100

B28 The Standard PO Box 82622

Lincoln NE 68501

800.547.9515 93024 www.standard.com

B29 ECOM 8350 N Central Expressway

Suite 650 A; Dallas, TX 75206

800.694.9888

Ext 273

B30 Southern Benefits . Southeastern Pipe Traders;

Southeastern Carpenters & Millwrights

PO Box 1449

Goodlettsville, TN 37070.1449

800.831.4914 See also: 224

B31 Great American Life Insurance Co. (GALIC)

Supplemental Insurance

PO Box 559002

Austin TX 78755-3010

800.880.2745 30054 5/17/12

B32 RX Maxcare PO Box 18024


800.259.7765 N/A 5/17/12

B33 RX PharmAvail Bld 400, Unit 100

Woodstock GA 30188

800.933.3734 610114 6/6/12 www.pharmavail.com

B34 FFS Atlanta Life Insurance Co. PO Box 897

Atlanta, GA 30301

404.659.2100 61093

B35 RX Procare RX Pharmacy Benefit Management

(PBM)

3090 Premier Parkway, Ste 100

Duluth GA 30097

800.699.3542 N/A 6/6/12 www.procarerx.com

B36 MS Marsh Affinity Group PO Box 14446

Des Moines IA 50306

800.245.6728 N/A 7/13/12 www.ellcabop.org

Admin for ELCA supplement to Medicare

B37 TPA Benefit Administrators PO Box 21308


803.739.0236

B38 TPA MedBen PO Box 1009

Newark OH 43058-1009

800.686.8425 74323 8/22/12 www.medben.com

http://www.emblemhealth.com/

http://www.pharmavail.com/

http://www.procarerx.com/

http://www.ellcabop.org/

March 9, 2015 49

SC


CHANGE

NOTE

B39 Medical Savings Insurance Company 5835 West 74th St


317.329.8222

B40 Total Claims Solution (TCS) PO Box 10888

Green Bay, WI 54307.0888

800.376.0110 See A41

B41 FFS Vytra Healthcare PO Box 9091

Melville NY 11747

866.808.9399 22264 09.17.07

B42 Midwest Security ( renamed UMR) PO Box 266

Onalaska, WI 546560.-0266

800.236.8672 07/24/08 Midwest Security is now UMR per Beth Earle

B43 Affinity Health Plan PO Box 981726

El Paso TX 79998-1726

800.774.0890 13334 9/6/12 www.affinityplan.org

B44 American’s Choice Health Plan, LLC PO Box 922043

Houston, TX 77292

800.633.4226

B45 Atlanticare PO Box 613

Hammonton, NJ 08037

888.28.2287 22304

B46 Guardian Life Ins. Co of America PO Box 423

E. Bridgewater, MA 02333

800.85.4542 64246

B47 TPA

RX

Pharmacy Data Management Inc. (PDM) PO Box 981726

El Paso TX 79998-1726

866.247.5678 None 9/6/12

B48 Select Health PO Box 30192


800.538.5038 None 9/7/12

B49 Fallon Community Health Plan PO Box 15121

Worchester MA 01615

800.868.5200 None 9/7/12

B50 Member Health PO Box 391180

Cleveland, OH 44139

888.868.5854

B51 Innoviant PO Box 8082

Wausau, WI 54402

877.559.2955

B52 Southern Planned Administrators PO Box 218180

Houston, TX 77218

281. 829.1033

B53 FFS National Foundation Life Insurance Company 777 Main Street


800.221.9039

817.878.3300

98205

B54 NGS American Inc. PO Box 7676

St. Clair Shores, MI 48080

810.779.7676

B55 TPA

RX

US Scripts 2425 West Shaw Ave

Fresno CA 93711

800.460.8988 None 9/7/2012 Usscript.com

B56 TPA MedSave USA 3035 Lakeland Hills Blvd

Lakeland FL 33805

800.226.3155 59069 9/7/2012 Medsaveusa.comI

B57 Southern Farm Bureau Life Ins. Co.

(Long Term Care)

PO Box 78

Jackson MS 39205

800.457.9611 None 9/14/2012

B58 AvMed Health PO Box 569000

Miami FL 33256-9000

800.452.8633 None 11/16/2012 www.avmed.org

B59 RX LDI Integrated Pharmacy Services 701 Emerson Rd,. Ste 301

Creve Coeur, MO 63141

866.516.3121 None 11/29/2012

B60 MS Comprehensive Benefits

(also known as CCG Benefits)

PO Box 9009

Melville NY 11747

800.231.7269 None 12/3/2012 www.ccg1800.com

http://www.avmed.org/

March 9, 2015 50

SC


CHANGE

NOTE

B61 HMO

American Behavioral 3680 Grandview Parkway, Ste 100

Birmingham AL 35243

800.925.8327 63103 1/24/2013 www.americanbehavioral.com

Managed care behavioral

B62 DEN Liberty Dental PO Box 26110

Santa Anna CA 92799

888.902.0349 CX083 2/4/13 www.libertydental.com

B63 Eastern Life & Health Insurance PO Box 10188

Lancaster PA 17605

888.654.7100 N/A 2/4/13

B64 United Medical Resources, Inc. 1329 E. Kemper Rd. #4100


800.837.3711

513.657.4880

31107

B65 FFS Compass Rose Health Plan PO Box 141501

Nashville TN 37214

877.531.1159 50946 2/22/13 www.compassrosebenefits.com

B66 TPA Assurant Health/ASA submission via

Healthsmart

PO Box 91604

Lubbock TX 79490

800.800.1212 58730 2/22/13 www.assuranthealth.com

B67 RX Navitus Health Solutions LLC PO Box 999

Appleton WI 54912-0999

866.268.2501 N/A 3/13/13 www.navitus.com

B68 PPO UPMC Health Benefits Inc

(Univ. of PA Medical Center)

PO Box 2999

Pittsburgh PA 15230

877.381.3764 N/A 3/13/13 http://www.upmchealthplan.com

B69 Meritain Health ( independent subsidiary of

Aetna)

PO Box 27267

Minneapolis MN 55427-0267

800.925.2272 41124 3/13/13 www.meritan.com

B70 DEN Decare Dental PO Box 1348


800.371.6561 N/A 3/22/13 www.decare.com

B71 UPMC Health Plan PO Box 2999

Pittsburgh PA 15230

877.381.3764 N/A 3/22/13 www.upmchealthplan.com

B72 HMO SC Solutions (Medicaid) PO Box 1458

Columbia SC 29202

888.366.6243 N/A N/A www.sc-solutons.org

B73 PPO Assurant Health/ASA PO Box 91604

Lubbock TX 79490

888.553.7654 56730 4/4/13 www.assuranthealth.com

B74 MCD

H MO

Keystone Mercy Health Plan (Keystone First

as of 6/1/2013)

PO Box 7115

London KY 40742-7115

800.521.6007 21207 4/29/13 www.keystonemercy.com

B75 Health Design Plus PO Box 5065

Findlay, OH 45839.5065

800.893.0777

B76 PPO International Association Benefits 1747 Pennsylvania Ave NW

Washington DC 20006

800.275.1171 95337

B77 TPA United Healthcare Administrators PO Box 121212

Marietta, GA 30067.0092

800.562.7079

B78 TPA ARM Group (Omnicare) 340 Quadrangle Dr.

Boilingbrook IL 60440

800.968.7222 88035 4/29/13 www.omnicarebenefits.com

B79 TPA Fox-Everett Inc. PO Box 6012

Ridgeland MI 39158-6012

877.476.6327 64069 4/29/13 www.foxeverett.com

B80 PPO Integrated Behavioral Health (IBH) PO Box 30018

Laguna Niguel CA 92607

800.395.1616 N/A 5/1/13 www.ibhcorp.com

B81 HM Benefits Administrators Inc PO Box 535078

Pittsburgh, PA 15253.5078

800.279.2624

B82 Avante Health (behavioral health) 1111 E. Herndon Ave., Ste 308

Fresno CA 93720

559.261.9060 AH001 5/28/2013 www.aventebehavioral.com

http://www.americanbehavioral.com/

http://www.libertydental.com/

http://www.navitus.com/

http://www.meritan.com/

http://www.decare.com/

http://www.upmchealthplan.com/

http://www.sc-solutons.org/

http://www.assuranthealth.com/

http://www.keystonemercy.com/

http://www.omnicarebenefits.com/

http://www.foxeverett.com/

http://www.ibhcorp.com/

http://www.aventebehavioral.com/

March 9, 2015 51

SC


CHANGE

NOTE

B83 MA Coventry Health Care of the Carolinas Inc

(Carelink)

PO Box 7102

London KY 40742

888-935-7284 25133 6/17/13 http://chccarolinas.coventryhealthcare.com

B84 Health Care Corporation

(Cotter Member Insurance)

203 Jandus Rd.

Cary, IL 60013

B85 Dormant

B86 Preferred One (aka Administrative Svcs /

Community Health Plan)

PO Box 59212


800.997.1750

763.847.4477

41147

B87 Health Alliance 102 E. Main St.

Urbana, IL. 61801

800.322.7451

B88 Gettysburg Health Administrators, Inc. PO Box 1169

Frederick MD 21702

800.497.4474

B89 RX RxEdo PO Box 2500, Ste 490

Plano TX 75093

888.879.7996 N/A 6/17/13 www.rxedo.com

B90 MA

HMO

First Choice VIP Care

(SNP) Special Needs Plan

PO Box 307

Linthicum MD 21090-0307

800.575.0418 37510 6/17/13 www.firstchoicevipcare.com

B91 Christian Brothers Employee Benefit Trust 1205 Windham Parkway

Romeoville IL. 60446

800.807.0400

B92 CareSource One South Main

Dayton, OH 45402

800.488.0134 31114

B93 University Health Alliance 700 Bishop St., Ste. 300

Honolulu HI 96813-4100

800.532.400 N/A 7/15/13

B94 The Capella Group (Care Entrée) PO Box 200368

Arlington, TX 76006

888.411.3888

B95 Sinclair Health Services PO Box 30827


888.800.2230 N/A 7/15/13

B96 Alternative Risk Management (ARM Ltd) 814 N.W. Highway

Arlington Heights IL 60004

800.392.1770 N/A 9/10/13 www.altrisk.com

B97 Nippon Life Insurance Company of America PO Box 39710

Colorado Springs, CO

80949.3910

800.937.6542 81264

B98 FFS American Pioneer Life Insurance PO Box 3509

Orlando, FL 32802

800.472.0869 60763 74048

56162

B99 TPA Group & Pension Administrators Inc. (GPA) PO Box 749075

Dallas TX 75374-9075

866.206.3224

800.827.7223

48143 3/14/11 www.gpatpa.com

Please note change of claims address

C01 SI Terminix Service PO Box 2627

Columbia, SC 29202

803.772.1783

C02 Foundation Benefits Administrators Inc 6300 Bridgepoint Pkwy, Bldg 3 #

400; Austin, TX 78730

888.368.7910 BOONG

C03 TPA Total Plan Services Inc 15455 North Dallas Parkway,

Ste 450,

Addison TX 75001

800.969.5238 11/19/10 Address change from: PO Box 251369

Plano, TX 75025

C04 TPA CBA Blue Po Box 2365

South Burlington VT 05407-2365

888.222.9206 03036 9/10/13 www.cbabluevt.com

C05 Strategic Outsourcing, Inc. PO Box 241508

Charlotte NC 28224


http://chccarolinas.coventryhealthcare.com/

http://www.altrisk.com/

http://www.gpatpa.com/

http://www.cbabluevt.com/

March 9, 2015 52

SC


CHANGE

NOTE

C06 MCO WellCare of SC formerly (UnitedHealthcare

Community Plan) Medicaid HMO

(formerly Unison Advantage)

PO Box 31224

Tampa FL 31224

888.588.9842 14163 9/18/13 www.wellcare.com

C07 AmeriBen Solutions PO Box 7186

Boise, ID 83707

800.786.7930 75137

C08 RX BeneCard PO Box 2187

Clifton NJ 07015

800.737.9528 N/A 11/8/13 www.benecard.com

C09 Health Plan Administrators PO Box 2638

Rockford, IL 61132

815.633.5800

C10 TPA Paradigm Administrators PO Box 1268

Tifton, GA 31793

912.386.1751

C11 TPA Benefit Management Services, Inc. PO Box 1178

Matthews, NC 28106.1178

800.228.1803

C12 TPA Benefit Management Inc. PO Box 1090

Great Bend KS 66210

800.290.1368 N/A 11/18/13 www.bmikansas.com

C13 FFS Central Reserve Life Insurance Company 17800 Royalton Rd.

Strongsville, OH 44136

800.321.3997

216.572.2400

61727 34097 see also 933 Preferred Healthcare Systems(PPO)

C14 BCBS of Mississippi State Plan

PO Box 23071

Jackson MI 39225.3071

800.709.0973

Sb731

11.30.07 www.bcbsms.com

C15 RX PCS, Inc. PO Box 52115

Phoenix, AZ 85072.2115

800.345.5413 Administers Drug Program for #237 . Guardian

Trust

C16 TPA Consolidated Benefits, Inc. PO Box 23686

Columbia, SC 29224

800.243.3110

803.736.5088

62359 BCBS

C17 TPA National Benefits 110 Gibraltar, Ste. 116

Horsham, PA 19044

800.635.7418

C18 Evolutions Healthcare Systems PO Box 5001

New Port Richey, FL 34656

800.881.4474 59313

C19 TPA Allegiance Benefit Plan Management PO Box 3018

Missoula MT 59806-3018

800.781.7204 75180 11/18/2013 www.abpmtpa.com

C20 MS Central States Indemnity of Omaha (CSI) PO Box 10815

Clearwater FL 33757-8815

855.664.5517 N/A 11/12/2013 www.medsup-csi.com

C21 MCO Advicare Corp Claims Department

PO Box 5547

Hauppauge NY 11788

888.781.4371 45423 12/10/13 www.advicareheatlh.com

C22 MCO Molina Healthcare of South Carolina PO Box 22664

Long Beach CA 90801

855.882.3901 46299 12/10/13 www.molinahealthcare.com

C23 Consumers Choice Health Plan

(Healthscope Benefits)

PO Box 91606

Lubbock TX 79490-1606

800.580.8736 45321 12/10/13 www.cchpsc.org

C24 Encompass Health Management System 6000 West Town Parkway Ste.

350


800.511.3389

C25 Medical Claims Services 1 Wall Street, Suite 2A

Ravenswood, WV 26164

888.225.0522 04258

C26 Interactive Medical Systems, Inc. PO Box 19108

Raleigh, NC 27619

800.367.9370

919.846.8400

C27 Select Benefit Administrators (SBA) PO Box 440

Ashland, WI 54802

800.497.3699 42137

http://www.abpmtpa.com/

http://www.cchpsc.org/

March 9, 2015 53

SC


CHANGE

NOTE

C28 Benefit Plan Management PO Box 536

Rocklyn, MA 02370

877.642.7500 37222

C29 TPA True Choice USA PO Box 251369

Plano, TX 75025

800.251.9665

C30 TPA Keenan & Associates PO Box 11431

Torrance, CA 90510

800.653.3626

C31 Consumer Health Solutions PO Box 3492


864.573.9541

C32 TPA Wells Fargo Financial PO Box 2801

Charleston WV 25330-2801

800.435.4351 87815 11/6/08

C33 The Destiny Health Plan PO Box 4628

Oakbrook, IL 60522

866.826.9345 36436

C34 TPA HTH Worldwide Insurance Services PO Box 39


866.510.8780

C35 TPA Trusted Plans PO Box 1894

Tacoma, WA 98401

800.426.9786 91078

C36 FFS North American Insurance Company 150 E. Gilmore St.

Madison, WI 53703

608.256.6600 68349

C37 FFS Old Surety Life Insurance of Texas PO Box 54407


800.272.5466 67326

C38 FFS Standard Life & Accident PO Box 25097


405.290.1000

C39 FFS Continental General Insurance Company 8901 Indian Hills Drive

Omaha, NE 68114

402.397.3200 71404

C40 AVERA Health Plans PO Box 381506


888.322.2115 46045

C41 International Benefits Adminstrators LLC 100 Garden City Plaza Ste 102

Garden City NJ 11530

800.422.7617 N/A 1/15/14 www.ibatpa.com

C42 Dormant

C43 Dean Health Plan PO Box 56099

Madison WI 53705

800.279.1301 N/A 1/15/14 www.deancare.com

C44 SI SC Medical Assn..Members Insurance Trust PO Box 11188

Columbia, SC 29211

800.327.1021

803.798.6200

C45 TPA Tall Tree Administrators PO Box 71747

Salt Lake City, UT 84171.0747

877.453.4201 88067

C46 Paid Prescription Drugs PO Box 700

Parsippany, NJ 07054

800.272.7243

C47 TPA Kanawha Employee Benefit Administrators PO Box 50098

Knoxville, TN 37950.0098

800.475.5150

864.240.3160

C48 Dormant

C49 Penn Western Benefits, Inc. PO Box 7834


919.292.4004

http://www.ibatpa.com/

http://www.deancare.com/

March 9, 2015 54

SC


CHANGE

NOTE

C50 TPA Tennessee Benefit Administrators PO Box 3257


901.685.8980

C51 Yale Health Plan PO Box 208217

New Haven, CT 06520.8217

203.432.0250

C52 TPA TPA of Georgia 2900 Chamblee.Tucker Rd.. #3,


770.451.7550

C53 MS Pekin Life Insurance Company 25005 Court St.

Perkin IL 61558

800.371.9622 N/A 1/15/14 www.pekininsurance.com

C54 Inter.Americas Ins. Corp. (OOIDA) PO Box 9510

Wichita, KS 67277.0510.

800.333.2525

316.794.2200

Owners Operators Independent

Drivers Assn

C55 TPA Plan Administration Associates 734 15th St, N.W., Ste. 500


202.393.6600

C56 FFS CompDent Insurance Co. PO Box 8236


800.342.5209

C57 World Travel Protection (CAA)

WTP Medical Claims

4600 Witmer Industrial Estates .

#2, Dept 101; Niagara Falls, NY

14305

800.456.4553

C58 MS Medico Insurance Co. PO Box 10386


800.228.6080 23160 1/15/14 www.gomedico.com

C59 MA

PPO

Humana Choice PPO

P.O. Box 14605


800.457.4708

877.227.8188

61101 10.05.07

C60 MA

PFFS

Instil Health Systems: InCare PO Box 7061

Camden, SC 29020.7061

877.446.7845 12168

C61 MA

RPPO

Instil Health Systems: InChoice PO Box 7061

Camden, SC 29020.7061

877.446.7845 12168

C62 MA

PFFS

BCBS of South Carolina:

Medicare Blue Private

PO Box 100133

Columbia, SC 29202

800.605.3256

C63 MA

PPO

BCBS of South Carolina: Medicare Blue &

Medicare Blue Plus/ Platinum Advantage

PO Box 100133

Columbia, SC 29202

800.605.3256 Revised 1.9.8; File Platinum Advantage for

DOS beginning 1.1.8

C64 MA

PPO

Blue Choice Health Plan:

Platinum Advantage

PO Box 6170

Columbia, SC 29260

877.275.0072 401 01.02.08 www.carolinablue.com

NEIC only 3 digits..401

C65 Presbyterian Healthcare Services 2501 Buena Vista DE

Albuquerque NM 87125

800.356.2219 N/A 1/27/14 www.phs.org

C66 SI Caterpillar, Inc. Benefits L.D. 487

E. Peoria, IL 61630

309.675.6611

C67 TPA Healthsmart Benefits Solutions PO Box 16387

Lubbock TX 79490

855.863.7271 37272 1/27/14 www.healthsmart.com

C68 FFS Dental Benefit Providers PO Box 389

Rockville, MD 20848

800.445.9090

C69 Healthsmart Benefits Solutions (formerly

Wells Fargo TPA)

PO Box 2451

Charleston WV 25329

888.440.7342 87815 1/27/14 www.healthsmart.com

C70 MS American Retirement Life (Cigna) PO Box 30010

Austin TX 78755-3010

888.459.1755 13193 2/24/14 www.americanretirementlife.com

C71 Johns Hopkins Healthcare PO Box 0607

Glen Burnie, MD 21060

800.261.2393

http://www.pekininsurance.com/

http://www.carolinablue.com/

http://www.phs.org/

http://www.healthsmart.com/

http://www.healthsmart.com/

http://www.americanretirementlife.com/

March 9, 2015 55

SC


CHANGE

NOTE

C72 TPA Advanced Insurance Administration 125 Merrill Dr, Ste 2000


888.242.4800

C73 PPO Union Pacific Railroad Employees Health

(First Health)

795 North 400 West


800.547.0421 87042 www.uphealth.com

C74 TPA National Capital Admin. Services (NCAS) PO Box 81556

Lincoln, NE 65801.1566

800.275.1521

C75 Florida 1st Service Administrators, Inc. PO box 3607

Winter Haven, FL 33885.3067

800.226.3155

C76 TPA Western and Southern Financial Group PO Box 5735

Cincinnati OH 45201

513.629.1800 N/A 2/24/14 www.westernsouthernlife.com

C77 MS Carpenters Hospitalization Plan 3611 Chester Avenue

Cleveland OH 44114

800.421.3959

C78 HMO Kaiser Foundation Health Plan(HMO) 3120 Highwoods Blvd.

Raleigh, NC 27604.1018

800.755.1925

919.981.6000

C79 Benefit Administrative System, Ltd. PO Box 17475 Jovanna Drive, #

18

Homewood, IL 60430

708.799.7400 36149

C80 Elder Health (MHN/HMC)

Mental Health Network/Health Maintenance

Care

PO Box 4433

Baltimore, MD 21223

888 776 8851

C81 FFS United Payers & United Providers (UPS &

UPS)

2275 Research Blvd.

Rockville, MD 20850

800.247.4144 Was America’s Health Plan

C82 Integrated Benefit Management Services

(IBMS)

PO Box 3819

Chatsworth, CA 91313

800.874.2155

C83 Freedom Life Insurance Company of America 3100 Burnett Plaza, 801 Cherry St,

Unit 33.


800.387.9027 62324

C84 FFS Central United Life Insurance Co. 2727 Allen Pkwy, 6th Floor

Houston, TX 77019.1150

800.669.9030

713.529.0045

61883

C85 FFS Loyal American Life Insurance Co. PO Box 30010

Austin, TX 78755.3010

500.633.6752 65722

C86 FFS National States Insurance Co. 1830 Craig Park Court

St. Louis, MO 63146

314.878.0101 60593

C87 TPA SIHO Insurance Services PO Box 1787

Columbus, IN 47202

800.873.2022

C88 TPA Adventist Risk Management PO Box 1928

Grapevine TX 76099

800.447.5002 75261 (supplemental retiree insurance)


C89 New Source Benefits PO Box 6305


800.476.1555

C90 Global Care Inc PO Box 247


866.807.6193

C91 TPA Plumbers & Steamfitters Local 440

Steward C. Miller (tpa)

PO Box 5769

Lafayette, IN 47903.5769

800.552.6550 See also #729; #706

C92 RX American Health Care 3001 Douglas St.

Roseville, CA 95661

800.872.8276

C93 Student Assurance Insurance Services P.O. Box 196

Still Water, MN 55085

800.328.2739

http://www.westernsouthernlife.com/

March 9, 2015 56

SC


CHANGE

NOTE

C94 Erin Group Administrators P.O. Box 7777

Lancaster, PA 17604

800 433.3746

717.581.1300

23250

C95 Midwest Security (A United Healthcare Co.) 2700 Midwest Dr.

Onalaska, WI 54650

800.236.8672

C96 RX Medtrack Services (Rx Manager) 6310 Lamar Ave. Ste. 230


800.771.4648

C97 TPA Gem Group 1200 Three Gateway Center

Pittsburgh, Pa 15222

800.242.8923

C98 TPA MBAMD (Medical Benefit Administrators of

Maryland, Inc.)

3103 Emmerton Rd.

Abingdon, MA 60631

800.899.9442

C99 Mutual Protective Medico Life Insurance Co. 1515 S 75th Street

Omaha, NE 68124

800.228.6080

402.398.0881

D01 REP Interlink Health Services 4950 NE Belknap Court, #205

Hillsboro, OR 97124

503.640.2000

D02 Insurance Administrator of America P.O. Box 5082

Mt. Laurel, NJ 08054

800.989.6739

D03 Pacific Source PO Box 7068

Eugene, OR 97401

800.624.6052 93029

D04 TPA LBA Health Plans Inc/Primary Select PO Box 17098

Owings Mill, MD 21117.7098

800.8158240

D05 SI

MA

UPMC Health Benefits Inc Medicaid (Univ. of

PA Medical Center)

PO Box 2999


877.381.3764 23281 www.upmchealthplan.com

D06 MS Southern California Bakery & Confectionary PO Box 22041

Commerce, CA 90022

323.722.7171

D07 TPA Benefit Coordinators Corporation 100 Ryan Ct, Suite 200


800.685.6100 24145

D08 Big Lots Associate Benefit Plan PO Box 9071

Dublin, OH 43017.0971

877.254.2363

D09 SI JM Family Enterprises 8019 Bayberry Road


800.892.0059

D10 TPA Seven Corners PO Box 90260


877.772.6763 The Ameracorp Volunteers

D11 MS Advanced Benefit Solutions PO Box 71490

Phoenix, AZ 85050

888.419.1094

D12 MS Secure Horizons Direct

United Healthcare

PO Box 12466

Pensacola, FL 32591

888.202.4340 Assigned incorrectly to D68

D13 Error in Assignment Duplicate Assignment; Use #816

Was Arcadian Health Plan/Community Care

D14 MA

PFFS

Medicare Plus Blue (BCBS of Michigan) 27000 Eleven Mile Road


800.249.5103 00210

00710

Facility

Professional

D15 MA

PFFS

SecurityChoice Enhanced Plus (Unicare) PO Box 795180


888.445.8916 80314

D16 MA

PFFS

Aetna Medicare Open™ Plan PO Box 14079


800 624 0756 60054

March 9, 2015 57

SC


CHANGE

NOTE

D17 MA

PFFS

PFFS

WellCare Healthcare Insurance of Arizona PO Box 4438

Scranton, PA 18505

866.238.9898 77072 www.wellcarepffs.com

D18 MA

HMO

CommunityCare Senior Health Plan PO Box 3249

Tulsa, OK 74101.3249

800.642.8065 73143

D19 MA

HMO

Healthfirst 65 Plus PO Box 5196

New York, NY 10274

888.260.1010 80141

D20 MA

HMO

Excellus Medicare Blue Choice Optimum PO Box 41915

Rochester, NY 14604

877.883.9577 00805 8/23/12 Update of NEIC only

D21 MA

HMO

Cariten Senior Health PO Box 22885

Knoxville, TN 37933

865.670.7790 62072

D22 MA

PFFS

Smart Value (BC of GA) PO Box 3897

Scranton, PA 18505

866.865.9329

D23 MA

HMO

America’s Health Choice Medical Plans, Inc. 762 South US Hwy. One PMB 224

Vero Beach, FL 32962

800.308.9823

D24 MA

HMO

Mount Carmel Health Plan (MCHP) MediGold PO Box 6111

Westerville, OH 43086

800.240.3870

D25 MA

HMO

Elder Plan Inc PO Box 199100

Brooklyn, NY 11219

718.921.8818 31625

D26 MA

HMO

Oxford Medicare Advantage PO Box 7082

Bridgeport, CT 06601

800.234.1228

D27 MA

PFFS

Secure Horizons Direct

PacifiCare

PO Box 25032

Santa Ana, CA 92799.5032

800.851.3802 70785

D28 MA

PFFS

Today’s Option

Pyramid Life Insurance Company:

PO Box 391885

Cambridge, MA 02139.1885

866.568.8921 48055

D29 MA

PFFS

UniCare Life & Health Insurance Company 233 S Wacker Drive, Suite 3900

Chicago, IL 68606

312.324.7000

D30 MA

PPO

UnitedHealthCare Insurance Company PO Box 150450

Hartford, CT 06115.0450

860.702.5000

D31 MA

HMO

Leon Medical Center Health Plan H5410 PO Box 65.9006

Miami, FL 33265

305.559.5366 37316

D32 MA

PPO

AARP Medicare Complete

(UnitedHealthCare)

PO Box 659735

San Antonio, TX 78265.9735

877.842.3210 87726 Updated

3/14/11

UnitedHealthCare & PacifiCare merged.

www.aarpmedicarecomplete.com

D33 MA

PFFS

Advantra Freedom PO Box 7154

London, KY 40742.7154

866.386.2330 25133 Neic changed 1/20 per Emdeon rep 25152

D34 MA

PFFS

Universal Health Care, aka

Any, Any, Any, Medicare Masterpiece Plan

PO Box 3211

St. Petersburg, FL 33731

866.690.4842 50528

D35 PPO USA MCO POB 10170

Phoenix, AZ 85064

800.291.5837 Associated w/ TPA

Unified Group Services

D36 TPA HOP / PSERS Health Administration Unit PO Box 2921

Clinton, IA 52733

800.773.7725

D37 West Virginia Local 152 Health and Welfare

Fund

5 Hot Metal St., Suite 200

Pittsburg, PA 15203

866.825.8152

D38 American Insurance Administrators GradMed PO Box 2348

Columbus, OH 43216

800.922.1245 Does not accept electronic claims

March 9, 2015 58

SC


CHANGE

NOTE

D39 New York Welfare Fund

Division 1181 A.T.U.

101.49 Wookhaven Boulevard,

Ozone Park, NY 11416

718.845.5800

D40 Minnesota Power Health Plans 30 W Superior St

Duluth, MN 55802

888.812.8800

D41 Bluegrass Family Health PO Box 22738

Lexington, KY 40522

800.787.2680 61124

D42 Care Improvement Plus

(special needs.chronic health conditions)

PO Box 4347

Scranton, PA 18505

866.686.2506 77082 MA, SNP.PPO

D43 Error in Assignment Duplicate Assignment; Use #816

was SE Community Care/Arcadian Health Plan

D44 MA

HMO

Independent Health PO Box 9066

Buffalo, NY 14231

866.517.8585 12X01 06.05.07 Also see #892

D45 MA

HMO

Highmark Security Blue

Keystone HealthPlan West

120 5th Ave

Pittsburgh, PA 15222.309

800.547.3627 06.05.07

D46 MA

HMO

Grouphealth Options, Inc PO Box 34585

Seattle, WA 98124

888.767.4670 91051 06.08.07

D47 MA

HMO

Touchstone Health PSO PO Box 33519

Indianapolis IN 46203.0519

888.777.0204 23856 09.05.07

D48 American Continental Insurance Co. PO Box 2368

Brentwood, TN 37024

615.337.1300 Duplicate Assignment – use D75

for Windsor Medicare Extra

D49 MS WEBTA

(Medicare Supplement)

PO Box 1928

Grapevine TX 76099.1928

800.342.5248 10.11.07

D50 Medicaid New York PO Box 1935

Albany NY 12201.1935

800.541.2831

D51 HMO AMERIGROUP Community Care PO Box 61010

Virginia Beach, VA 23466.1010

800 600 4441 Georgia Medicaid HMO

D52 MA HMO WellCare of Georgia PO Box 31224

Tampa, FL 33631

866 231 1821 14163 Georgia Medicaid HMO

D53 MA

PFFS

Sierra Optima Plus Claims

(Sierra Health and Life Ins. Co., Inc.) PO Box 15645

Las Vegas, NV 89114.5645

888.274.2207

76342

D54 MA

SNP

SNP

Gateway Health Plan Medicare Assured

(special needs.chronic health conditions)

PO Box 11560

Albany, NY 12211.0655

800.685.5209 60550 05.24.07 May be HMO or PPO. Need to call for info. if

not a participating provider.

D55 MCO

Total Carolina Care, Inc (Absolute Total Care) 1441 Main Street

Columbia SC 29210

866.433.6041 68055 01.10.08 www.totalcarolinacare.com

MEDICAID PLAN

D56 MA

HMO

Citrus Health Care Inc. PO Box 20547

Tampa FL 33622

866.769.1157 01.31.08 Citrushc.com

Paper Claims Only

D57 MA

PFFS

CIGNA Medicare Access PO Box 22174

Tempe AZ 85285.2174

800.577.9410 86033 01.31.08 www.cignamedicare.com

D58 MA

HMO

Bravo Health Medicare Advantage PO Box 4433

Baltimore MD 21223

800.556.1570 52192 05.08.08 Bravohealth.com

D59 REP SDS Smart Data Solutions 4676 Hwy 41 N

Springfield, TN 37172

800.591.6764 None 05.16.08 Repricer for PPO

http://www.totalcarolinacare.com/

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NOTE

D60 MCO Amerigroup Community Care of SC PO Box 31789

Virginia Beach VA 234661789

800.600.4441 04.02.08 www.Amerigroupcorp.com

Medicaid MCO

D61 MA

HMO

America’s 1st Choice Health Plan PO Box 210769

Columbia SC 29210

866.321.3947 20553 01.23.08 www.americas1stchoice.com

D62 MA

PFFS

UnitedHealthcare Medicare Solutions PO Box 31353

Salt Lake City, UT 84131-0353

866.579.8774

87726 3/20/12 File electronically.

Name change from Secure Horizons Direct

(United Healthcare)

D63 MA

HMO

Univera Senior Choice Secure PO Box 23000

Rochester NY 14692

800.617.1114

16107

10.30.07

D64 MA

PFSS

Empire Healthchoice Assurance, Inc.

Medicare Advantage PFFS Smart Value

PO Box 100300 Claims

Processing, Columbia, SC 29204

803.788.8562 11.19.07 Include 3 digit alpha prefix preceding Patient

ID#..File thru local BC

D65 MA

HMO

Anthem Senior Advantage PO Box 37690

Louisville KY 40233.7180

888.290.9160 12.11.07 File thru local Blue Cross

D66 HMO CHCCares of South Carolina 140 Stone Ridge Dr

Columbia, SC 29210

866.802.2474 Duplicate Assignment – use D17

for Wellcare Health Insurance of Arizona

D67 MA Blue Cross of Florida Health Options

(Medicare Advantage Plan)

PO Box 1798

Jacksonville FL 32231

877.352.2583 12.17.07 File Claims To Local Blue Cross

D68 MCO

Carolina Crescent Health Plan, Inc

Virginia Commonwealth Univ. Health System

PO Box 5386

Richmond VA 23220-5386

866.748.8661

803.251.6630

12K85 01.10.08 www.carolinachp.com MEDICAID PLAN

Assigned incorrectly as D12

Claims address change 6/1/10

D69 MA

HMO

Healthspring (Cigna) PO Box 981804

El Paso TX 79998

800.230.6138

63092

12.10.13 www.healthspring.com

D70 PPO

MA

Freedom Blue PO Box 10030, Claims Processing

Columbia SC 29202

803.788.8562 866.306.1061. Pittsburg PA

FILE THRU LOCAL BC

D71 MA

HMO

Keystone 65 PO Box 7799

Philadelphia PA 19101.7799

800.227.3116

12.11.07 www.site65.com

Independent BCBS

D72 PPO PPONEXT 5080 Spectrum Dr. Ste 650 W.

Addison TX 75001-6880 800.860.6381 36332 06.12.08 www.pponext.com

D73 PPO HSCG Kentucky 501 Darby Creek Rd, Ste 55

Lexington KY 40509 866.664.3261 20896 6.12.08 Repricer Beech St.

D74 PPO Dart Management Corp. PO Box 318

Mason MI 48854-0318 800.248.0457 06172 6.12.08

D75 MA

HMO

Windsor Medicare Extra PO Box 269025

Plano TX 75026.9025

866.270.5223 62153 1.9.8 www.windsormedicareextra.com

Assigned incorrectly to D48 & D17

D76 Healthgram

(Primary PhysicianCare, Inc)

PO Box 11098

Charlotte NC 28220-1088

877.371.3720 56144 2.24.11 www.healthgram.com

D77 PPO Alliance for Affordable Services PO Box 612547

Dallas TX 75261

800.733.2242 2.24.11 www.affordableservices.com

D78 MA PPO &

FFS

America’s 1st Choice Insurance Company of

North Carolina

PO Box 210459

Columbia SC 29221-0459

866.321.3947 26078 4/19/11 www.americas1stchoice.com

D79 TPA

RX

Employee Health Insurance Management

(EHIM) pharmacy benefit

26711 Northwestern Highway Ste

400

Southfield MI 48033

800.311.3446 005285 www.ehimrx.com

D80 PPO Stirling Benefits 20 Armony Lane

Milford CT 06460

800.447.6689 1/17/14 www.stirlingbenefits.com

http://www.amerigroupcorp.com/

http://www.americas1stchoice.com/

http://www.carolinachp.com/

http://www.site65.com/

http://www.pponext.com/

http://www.windsormedicareextra.com/

http://www.healthgram.com/

http://www.stirlingbenefits.com/

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D81 MS Heartland National Life Insurance Co. PO Box 2878


800.872.3860 N/A 2/24/14 www.heartlandnational.net

D82 DEN Solstice (dental and vision)

PO Box 14009

Lexington KY 40512

877.760.2247 N/A 2/27/14 www.solsticebenefits.com

D83 Globality North America 888 C8th Ave, Box 222

New York, NY 10019

212.796.0854 3/21/14 www.northamericaglobilites.com

(international health insurer)

D84 Previously assigned in error 3/21/14 Corrected on 7/24/14

D85 US Fire Insurance Company Global Claims Administration

3195 Linwood Rd., Ste 201

Cincinnati OH 45208

800.513.2981 3/21/14

D86 Amerihealth District of Columbia PO Nox 7342

London KY 40742

202.408.2237 77002 3/21/14 www.amerihealthdc.com

D87 Lifestyle Healthcare (Medova Healthcare) 345 N. Riverview Ste 600

Wichita KS 67203

866.827.6607 3/21/14 www.medova.com

D88 HCC Medical Insurance Services PO Box 2005

Farmington Hills MI 48333

800.605.2282 3/21/14 www.hccmis.com

D89 MS Anthem BlueCross and BlueShield PO Box 60007

Los Angels CA 90060

866.266.2268 3/21/14 www.anthem.com

D90 Cenpatico Behavioral Health

(SCHIP partner w Absolute Total Care)

PO Box 7001

Farmington MO 63640

866.433.6041 68058 7/9/09 www.cenpatico.com

D91 Absolute Total Care (currently out of business

2010

Healthy Connection Kids

PO Box 3050

Farmington MO 63640-3821

877.552.4642 68055 3/04/09 Effective DOS 3.1.09

D92 HCK

MMC

Select Health


PO Box 7120

London KY 40742

888.276.2020 23285 05.08.08 Effective DOS 5.1.8

D93 HCK

MMC

(United Healthcare Community Plan)

Unison Health Plan


250 Berryhill Rd. Cola., SC 29210

POB 1148.Monroeville PA

15146

803.798.5852 32006 05.08.08

3/5/11

Effective DOS 5.1.8

Unison’s name changed as of 3/5/11 to United

healthcare Community Plan

D94 HCK

MMC

AMERIGROUP Community Care


PO Box 61010

Virginia Beach VA 23466.1010

800.600.4441 05.08.08 Effective DOS 5.1.8 Not valid 3/1/09

D95 HCK

MMC

Total Carolina Care, Inc.


1441 Main St.

Columbia SC 29210

866.843.6041 68055 05.08.08 Effective DOS 5.1.8

D96 HCK

MMC

CHCcares of South Carolina


140 Stone Ridge Dr.

Columbia SC 29210

866.802.2474 25151 05.08.08 Effective DOS 5.1.8

D97 HCK

HMO

BlueChoice Medicaid


PO Box 6170

Columbia SC 29260

800.574.8661

D98 HCK

MMC

Carolina Crescent


1201 Main St. Ste. 970

Columbia SC 29201

866.748.8661

803.251.6630

12K85 05.08.08 Effective DOS 5.1.8

D99 MA Medicare Advantage

E01 LIA United Automobile Insurance Co.


PO Box 921399

Norcross GA 30010

866.913.6866 None 6/12/12 Liability Insurance

E02 LIA National Document Center


PO Box 268997

Oklahoma City OK 73126

800.274.7865 None 6/12/12

Liability Insurance

http://www.solsticebenefits.com/

http://www.northamericaglobilites.com/

http://www.amerihealthdc.com/

http://www.medova.com/

http://www.hccmis.com/

http://www.anthem.com/

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E03 LIA Safe Auto Insurance


PO Box 182384

Columbus OH 43218


E04 LIA Intercontinental Acceptance


PO Box 1709

Huntersville NC 28070-1709


E05 LIA Assurance America


PO Box 725009

Atlanta GA 31139


E06 LIA Ramsey Adjustment Services


Po Box 21245

Columbia SC 29221


E07 LIA Acceptance Insurance Co.


PO Box 150769

Nashville TN 37215


E08 LIA USAA Auto Injury Solutions


Mail Processing Center

PO Box 5000

Daphne AL 36526


E09 LIA Assurant America


PO Box 6099

Scottsdale AZ 85261


E10 LIA Esurance


PO Box 4410

Alpharetta GA 30023


E11 LIA Praetorian Insurance


PO Box 810839

Dallas TX 75381


E12 LIA Frontier Adjusters


PO Box 3056

Myrtle Beach SC 29577


E13 LIA Travelers Insurance


PO Box 473508

Charlotte NC 28247


E14 LIA CIS


10700 Montgormery Rd., Ste 210

Cincinnati OH 45242


E15 LIA Liberty Mutual Insurance


Auto Claims

175 Berkely St.

Boston MA 02116


The main office is listed as this has multiple

offices

E16 MS Government Personnel Mutual Life Insurance

Co. (GPM)

PO Box 2679

Omaha NE 68103

866.865.7631 None 3/21/14 www.gpmlifemedsup.com

E17 PPO 6 Degrees Health Inc. 1915 NW Ambergien Pkwy, Ste

400

Beaverton OR 97006

503.640.9933 None 3/27/14 www.6degreeshealth.com

E18 United Healthcare Life Insurance Company

(UHCLIC)

PO Box 31374


800.657.8205 37602 4/14/14 www.unitedhealthcareonline.com

Network is United Healthcare Navigate

http://www.gpmlifemedsup.com/

http://www.6degreeshealth.com/

http://www.unitedhealthcareonline.com/

March 9, 2015 62

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E19 FFS Windsor Health Plan (Wellcare) PO Box 31372

Tampa FL 33631-3372

866.270.2537 14163 4/25/14

E20 RX VRX Pharmacy Services PO Box 9780


877.879.9722 N/A 4/28/14 www.myvrx.com

E21 HP Enterprise Services

(Medicaid Peachcare for Kids) GA Medicaid

program

PO Box 105204

Tucker GA 30085

800.766.4456 77034 5/12/14

E22 MS Plumbers Welfare Fund Local 130 UA 1430 West Washington Blvd 3rd

Floor

Chicago IL 60607

312.226.4200 6/11/14 www.plumberslu130ua.org

E23 TPA Maine Sense

(Patients Advocates)

PO Box 1959

Gray ME 04039

800.290.8559 10525 6/11/14 www.mainsense.org

E24 RX PBM Plus

(Pharmacy Benefit Management)

300 Technecenter Drive, Ste C

Milford OH 45150

800.263.2178 N/A 6/11/14 www.pbmplus.com

E25 PPO PHX-Preferred Administrators

(South Carolina Health Cooperative SCHC)

PMB #418 15560 N FLW BLVD

Scottsdale AZ 85260

88057 7/8/14 www.theschc.com

E27 PPO GWH-CIGNA

(Great West Healthcare)

PO Box 188061

Chattanooga TN 37422-8061

800.228.1803 62308 7/17/14 www.cinga.com

claims address changed from 1000 Great West

Drive, Kennett Mo 63857 (7/1/14)

E28 PPO Coresource

(GulfStream Aerospace Corp.)

PO Box 105

Arnold MD 21012

855-402-8831 CB624 8/25/14 www.cinga.com

E29 PPO Best Life and Health Insurance Company PO Box 890

Meridian ID 83680-0890

800.433.0088 95604 9/18/14 www.bestlife.com

E30 TPA Business Administrators and Consultants Inc. PO Box 107

Reynoldsburg OH 43068

800.521.2654 N/A 10/8/14 www.bactpa.com

E40 MA

HMO

Optimum Healthcare

(HMO-POS) Medicare Advantage

PO Box 151258

Tampa FL 33684

866.245.5360 20133 10/13/14 www.youroptimumhealthcare.com

E41 RX Medtrak 7101 College Blvd, Ste 1000

Overland Park KS 66210

800.771.4648 800004 10/13/14 www.medtrakservices.com

E42 RX True Rx 4 Williams Brothers Dr.

Washington IN 47501

866.921.4047 N/A 11/7/14 www.truerx.com

http://www.myvrx.com/

http://www.plumberslu130ua.org/

http://www.mainsense.org/

http://www.pbmplus.com/

http://www.cinga.com/

http://www.bestlife.com/

http://www.bactpa.com/

http://www.youroptimumhealthcare.com/

http://www.medtrakservices.com/

http://www.truerx.com/

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E43 HMO The Health Plan Insurance Company 52160 National Road East

St. Clairsville, OH 43950

740.699.6273 N/A 11/7/14 www.healthplan.org

E44 TPA Alternative Insurance Resource Inc. PO Box 680787

Birmingham AL 35266-0787

800.451.4318 N/A 11/7/14 www.yourtpa.com

E45 Unified Life Insurance PO Box 25326

Overland KS 66225-5326

913-685-2233 N/A 11/20/14 www.unifiedlife.com

E46 Toledo Firefighters Health Plan PO Box 5810

Troy MI 48007-5810

419-255-5314 N/A 1/23/15 www.tffhp.org/who

E47 Healthy Connections Prime – First Choice VIP

Care PLUS

Dual Medicare/Medicaid Plan

PO Box 853917


888-978-0862 77009 1/30/15 www.selecthealthofsc.com

E-48 Healthy Connections PRIME – Advicare

Advocate


PO Box 5547

Hauppauge NY 11788

888-781-4371 45423 1/30/15 www.advicarehealth.com

E-49 Healthy Connection PRIME – Molina Dual

Options


PO Box 22664

Long Beach CA 90801

855-701-4887 46299 1/30/15 www.molinhealthcare.com

E-50 Advocate Healthy Connections PRIME –

Absolute Total Care


PO Box 3060

Farmington MO 63640-3821

855-735-4398 68069 1/30/15 www.absolutetotalcare.com

E51 Choice Benefits

(ArcBest Corporation)

Self Insured

3801 Old Greenwood Rd

Ft Smith AR 72903

800-451-6907 75278 2/6/15

E52 Aetna Better Health Medicaid

(Medicaid)

PO Box 62198

Phoenix AZ 85082-2198

866-638-1232 23228 3/9/15 www.aetnabetterhealth.com

E53 Medica Healthcare PO Box 56-6116

Miami FL 33256

800-348-5548 78857 3/9/15 www.medicaplans.com

http://www.healthplan.org/

http://www.unifiedlife.com/

http://www.tffhp.org/who

http://www.selecthealthofsc.com/

http://www.advicarehealth.com/

http://www.molinhealthcare.com/

http://www.absolutetotalcare.com/

http://www.aetnabetterhealth.com/

http://www.medicaplans.com/

South Carolina · March 9, 2015 2 Carrier / Payer Codes assigned for South Carolina Definitions:...

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