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.
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
Greensboro, NC 27420
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
Greenville, SC 29608
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
March 9, 2015 6
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Salt Lake City UT 84130
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
March 9, 2015 7
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Spartanburg, SC 29303
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Fort Worth, TX 76107
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
March 9, 2015 9
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Jacksonville, FL 32245.9080
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
Chattanooga, TN 37416
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
March 9, 2015 10
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
231 FFS Savers Life Insurance Co. 8064 North Point Blvd.
Winston Salem, NC 27106
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
Bellingham, WA 98227.5348
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
San Antonio, TX 78279
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
March 9, 2015 11
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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,
Fort Worth, TX 76102
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
Charlotte, NC 28222.0887
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
Overland Park, KS 66212
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.
Jacksonville, FL 32204
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
San Antonio, TX 78268
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
Kansas City, MO 64116
800.231.4015 20356
287 TPA Community Health Plan PO Box 14467
Cincinnati, OH 45250
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
Oklahoma City, OK 73126
800.654.9106 68462
March 9, 2015 13
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Spartanburg, SC 29304
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
Washington, DC 20001
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
San Antonio, TX 78269
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
Charleston, SC 29413
803.722.2115 67466 BCBS uses Preferred Blue network
316 FFS Professional Insurance Corp. PO Box 1410
Jacksonville, FL 32231
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
800.410.7778 44444 Coventry Health Care
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
800.410.7778 62413 Coventry Health Care
328 Provider Select, Inc. PO Box 330070
Fort Worth, TX 76163
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
Chicago, IL 60666.0904
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
March 9, 2015 15
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
March 9, 2015 16
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Minneapolis, MN 55440
800.444.6965 41045
365 SI Gerber Children’s Wear, Inc. PO Box 2126
Greenville, SC 29602
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
Salt Lake City, UT 84109
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
March 9, 2015 17
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Spartanburg, SC 29304
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
Salt Lake City, UT 84109
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
Columbia, SC 29260.6002
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.
Greenville, SC 29614
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
March 9, 2015 18
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Columbia, SC 29202.3102
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Columbia, SC 29202.3234
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
March 9, 2015 20
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Indianapolis, IN 46250.0440
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
Fort Worth, TX 76161
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
866.732.1017 03.26.08 Placed back in active status
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
Indianapolis IN 43242
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
800.621.6360 95266 Coventry Health Care
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
Spartanburg, SC 29304
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
March 9, 2015 22
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Salt Lake City, UT 84110
800.352.5150
802.579.3400
62952
510 TPA Equitable Plan Services PO Box 720460
Oklahoma City, OK 73172
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
Jacksonville, FL 32232
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Spartanburg, SC 29307
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
Greenville, SC 29606
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
Atlanta, GA 30358.2677
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
Birmingham, AL 35202
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
March 9, 2015 24
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
547 PPO Harrington Health PO Box 30544
Salt Lake City UT 84130-0544
800.235.7160 62061 5/13/09
548 CompBenefits Insurance Co. PO Box 804483
Chicago, IL 60680.4106
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
Indianapolis, IN 46250
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
765.778.1535 03.26.08 Placed back in active status
557 Americorps PO Box 33757
Indianapolis, IN 46203.0757
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
Indianapolis IN 46206
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
765.778.1535 03.26.08 Placed back in active status
567 Eastern Benefit Systems 200 Freeway Drive E
East Orange, NJ 07018
800.524.0227
568 TPA Health Risk Management, Inc. PO Box 1479
Minneapolis, MN 55440.1479
800.422.0055 55438
March 9, 2015 25
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Cincinnati, OH 45250
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
Salt Lake City, UT 84130
800.998.5033
582 FFS USAA General Indemnity Co.
USAA Life Insurance Co.
9800 Fredericksburg Rd.
San Antonio, TX 78288
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.
Indianapolis, IN 46278.1719
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
March 9, 2015 26
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
591 FFS Old American Insurance Co. 3520 Broadway
Kansas City, MO 64111
800.733.6242
816.753.4900
Attn: Personnel
592 SI Contec 525 Locus Grove Rd.
Spartanburg, SC 29303
864.503.8333
593 TPA Mutual Assurance Administrators, Inc. PO Box 42096
Oklahoma City, OK 73123
800.648.9652 37256
594 SI Norwest Financial 206 Eighth Street
Des Moines, IA 50309
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
Columbia, SC 29209.1639
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Greenville, SC 29615
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
Chattanooga, TN 37402
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
Louisville, KY 40512
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Charlotte, NC 28273.8102
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
Spartanburg, SC 29306
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
Jacksonville, FL 32247.0269
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
Salt Lake City UT 84130
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
Columbia, SC 29202.0427
800.433.3036
803.256.6265
March 9, 2015 30
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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.
Spartanburg, SC 29303
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
Southfield, MI 48075
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
March 9, 2015 31
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Des Moines, IA 50309
800.242.2192
760 TPA Key Benefit Administrators PO Box 55210
Indianapolis, IN 46205
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
March 9, 2015 32
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Indianapolis, IN 46206.6001
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
Charlotte, NC 28220.2995
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
Address change 8/5/14
March 9, 2015 33
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Salt Lake City UT 84130-0786
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
Pensacola, FL 32591.0130
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
Pensacola, FL 32591.0130
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
Salt Lake City, UT 84130
877.801.3507
March 9, 2015 34
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Salt Lake City UT 84130-0541
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
Little Rock, AR 72221
888.604.9397
March 9, 2015 35
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Indianapolis, IN 46220
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
March 9, 2015 36
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Birmingham, AL 35283
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
Bellingham, WA 98227.5348
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
Kansas City, MO 64121
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
March 9, 2015 37
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Greenville, SC 29602
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
Charleston, SC 29420
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
Charlotte, NC 28217.4246
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
March 9, 2015 38
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Spartanburg, SC 29304
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.
March 9, 2015 39
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Columbia, SC 29260.6170
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
Columbia, SC 29202.1640
90440 4/29/09 Updated information
March 9, 2015 40
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Greensboro, NC 27438.6303
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,
Winston.Salem, NC 27114
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
March 9, 2015 41
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Alpharetta, GA 30009
888.650.6566
967 Underwriters Safety & Claims PO Box 23507
Louisville, KY 40223
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
March 9, 2015 42
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Winston Salem, NC 27101
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
Indianapolis, IN 46268
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
Charleston, SC 29492
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
Atlanta, GA 30350.1853
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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.
Salt Lake City, UT 84116
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
San Antonio, TX 78216
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
Greensboro, NC 27427
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
March 9, 2015 44
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
(liability insurance)
1 Geico Center
Macon GA 31296
800.841.8842 10/16/11 www.geico.com
A36 State Farm
(liability insurance)
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
Greensboro, NC 27438.6304
800.999.1147
A39 Complete Benefits Solutions PO Box 3649
Greenville, SC 29608
866.270.2316
A40 TPA Strategic Resource Co. PO Box 23759
Columbia, SC 29224.3759
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.
(liability insurance)
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
(liability insurance)
PO Box 31001
Tampa FL 33631
10/17/11
A48 SC Farm Bureau Insurance Company
(liability insurance)
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
800.437.0511 10/31/11 Limited liability insurance
A56 QBE Specialty Insurance PO Box 212128
Columbia SC 29221
803.612.7772 10/31/11 Limited liability insurance
A57 ESIS AGL Southeast Hub
(limited liability insurance)
PO Box 5128
Scranton PA 18505-0560
800.367.5189 11/14/11 Limited liability insurance
www.esis.com
A58 Dairyland Insurance Company
(limited liability insurance)
PO Box 8041
Stevens Point WI 54481
919.751.7828 11/4/11
A59 Access General Insurance Company
(limited liability insurance)
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
(liability insurance)
PO Box 648
Battle Creek MI 49016
866.999.0898 N/A 1/17/12 www.universalnorthamerica.com
A69 Omni Insurance Co.
(liability insurance)
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
Salt Lake City UT 84130
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
March 9, 2015 46
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Birmingham, AL 35238
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
San Antonio, TX 78205
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
Atlanta, GA 30374.0801
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
Indianapolis IN 46206
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
Minneapolis MN 55440
3/8/12 N/A www.ucare.org
A90 Employee Benefit Claims, Inc. 820 Parish Street
Pittsburgh, PA 15220
800.922.4966
312.696.3660
A91 States General Life Ins Co. 115 West 7th St, Suite 1200
Fort Worth, TX 76102.7012
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
Fort Worth, TX 76113.2522
800.433.1672
March 9, 2015 47
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Richardson TX 75085-3925
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
Minneapolis, MN 55440.1272
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.
Winston.Salem, NC 27106
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
March 9, 2015 48
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Indianapolis IN 46217
888.358.9484 RLHA1 www.renaissancedental.com
B20 FMH Benefit Services, Inc. P.O. Box 25946
Overland Park, KS 66225
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
Oklahoma City, OK 73154
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
Columbia, SC 29221.1308
803.739.0236
B38 TPA MedBen PO Box 1009
Newark OH 43058-1009
800.686.8425 74323 8/22/12 www.medben.com
March 9, 2015 49
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
B39 Medical Savings Insurance Company 5835 West 74th St
Indianapolis, IN 46278.1757
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
Salt Lake City UT 84123
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
Fort Worth, TX 76102
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
March 9, 2015 50
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Cincinnati, OH 45216
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
Minneapolis MN 55440
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
March 9, 2015 51
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Minneapolis, MN 55459
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
Salt Lake City UT 84130
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
888.836.7764 03.26.08 Placed back in active status
March 9, 2015 52
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Des Moines, IA 50266
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
March 9, 2015 53
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Spartanburg, SC 29304
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
Minneapolis, MN 55440.0039
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
Oklahoma City, OK 73193
800.272.5466 67326
C38 FFS Standard Life & Accident PO Box 25097
Oklahoma City, OK 73193
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
Birmingham, AL 35238
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
Greensboro, NC 27417
919.292.4004
March 9, 2015 54
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
C50 TPA Tennessee Benefit Administrators PO Box 3257
Spartanburg, SC 29304
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,
Atlanta, GA 30341.4128
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
Washington, DC 20005
202.393.6600
C56 FFS CompDent Insurance Co. PO Box 8236
Chicago, IL 60680.8236
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
Des Moines, IA 50306
800.228.6080 23160 1/15/14 www.gomedico.com
C59 MA
PPO
Humana Choice PPO
P.O. Box 14605
Lexington, KY 40512.4601
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
March 9, 2015 55
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
C72 TPA Advanced Insurance Administration 125 Merrill Dr, Ste 2000
Little Rock, AR 72211
888.242.4800
C73 PPO Union Pacific Railroad Employees Health
(First Health)
795 North 400 West
Salt Lake City, UT 84103
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.
Fort Worth, TX 76102
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)
Address change 2/24/11
C89 New Source Benefits PO Box 6305
Spartanburg, SC 29304
800.476.1555
C90 Global Care Inc PO Box 247
Alpharetta, GA 30009
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
March 9, 2015 56
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
Overland Park, KS 66202
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
Pittsburgh, PA 15230
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
Pittsburgh, PA 25145
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
Jacksonville, FL 32256
800.892.0059
D10 TPA Seven Corners PO Box 90260
Indianapolis, IN 46290.0260
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
Southfield, MI 48034
800.249.5103 00210
00710
Facility
Professional
D15 MA
PFFS
SecurityChoice Enhanced Plus (Unicare) PO Box 795180
San Antonio, TX 78279
888.445.8916 80314
D16 MA
PFFS
Aetna Medicare Open™ Plan PO Box 14079
Lexington, KY 40512.4079
800 624 0756 60054
March 9, 2015 57
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
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
March 9, 2015 59
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
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
March 9, 2015 60
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
D81 MS Heartland National Life Insurance Co. PO Box 2878
Salt Lake City UT 84110
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
Healthy Connection Kids
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
Healthy Connection Kids
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
Healthy Connection Kids
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.
Healthy Connection Kids
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
Healthy Connection Kids
140 Stone Ridge Dr.
Columbia SC 29210
866.802.2474 25151 05.08.08 Effective DOS 5.1.8
D97 HCK
HMO
BlueChoice Medicaid
Healthy Connection Kids
PO Box 6170
Columbia SC 29260
800.574.8661
D98 HCK
MMC
Carolina Crescent
Healthy Connection Kids
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.
(liability insurance)
PO Box 921399
Norcross GA 30010
866.913.6866 None 6/12/12 Liability Insurance
E02 LIA National Document Center
(liability insurance)
PO Box 268997
Oklahoma City OK 73126
800.274.7865 None 6/12/12
Liability Insurance
March 9, 2015 61
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
E03 LIA Safe Auto Insurance
(liability insurance)
PO Box 182384
Columbus OH 43218
800.723.3288 None 6/12/12 Liability Insurance
E04 LIA Intercontinental Acceptance
(liability insurance)
PO Box 1709
Huntersville NC 28070-1709
704.895.1206 None 6/12/12 Liability Insurance
E05 LIA Assurance America
(liability insurance)
PO Box 725009
Atlanta GA 31139
888.223.8409 None 6/12/12 Liability Insurance
E06 LIA Ramsey Adjustment Services
(liability insurance)
Po Box 21245
Columbia SC 29221
803.77.1390 None 6/12/12 Liability Insurance
E07 LIA Acceptance Insurance Co.
(liability insurance)
PO Box 150769
Nashville TN 37215
800.779.2103 None 6/12/12 Liability Insurance
E08 LIA USAA Auto Injury Solutions
(liability insurance)
Mail Processing Center
PO Box 5000
Daphne AL 36526
800.531.8722 None 6/12/12 Liability Insurance
E09 LIA Assurant America
(liability insurance)
PO Box 6099
Scottsdale AZ 85261
800.245.1505 None 6/12/12 Liability Insurance
E10 LIA Esurance
(liability insurance)
PO Box 4410
Alpharetta GA 30023
800.378.7262 None 6/12/12 Liability Insurance
E11 LIA Praetorian Insurance
(liability insurance)
PO Box 810839
Dallas TX 75381
378.814.6716 None 6/12/12 Liability Insurance
E12 LIA Frontier Adjusters
(liability insurance)
PO Box 3056
Myrtle Beach SC 29577
910.328.1399 None 6/12/12 Liability Insurance
E13 LIA Travelers Insurance
(liability insurance)
PO Box 473508
Charlotte NC 28247
800.759.6194 None 6/12/12 Liability Insurance
E14 LIA CIS
(liability insurance)
10700 Montgormery Rd., Ste 210
Cincinnati OH 45242
800.236.8599 None 6/12/12 Liability Insurance
E15 LIA Liberty Mutual Insurance
(liability insurance)
Auto Claims
175 Berkely St.
Boston MA 02116
617.357.9500 None 6/12/12 Liability Insurance
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
Salt Lake City UT 84131-0374
800.657.8205 37602 4/14/14 www.unitedhealthcareonline.com
Network is United Healthcare Navigate
March 9, 2015 62
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
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
Salt Lake City UT 84109
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
March 9, 2015 63
SC
CODE TYPE NAME ADDRESS PHONE NAIC NEIC DATE OF
CHANGE
NOTE
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
Richardson TX 75085-3914
888-978-0862 77009 1/30/15 www.selecthealthofsc.com
E-48 Healthy Connections PRIME – Advicare
Advocate
Dual Medicare/Medicaid Plan
PO Box 5547
Hauppauge NY 11788
888-781-4371 45423 1/30/15 www.advicarehealth.com
E-49 Healthy Connection PRIME – Molina Dual
Options
Dual Medicare/Medicaid Plan
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
Dual Medicare/Medicaid Plan
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
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