[PDF] [PDF] Payer ID provider number reference - Independence Blue Cross

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Payer ID provider number reference — Professional 1 Use this guide as a reference tool when submitting professional claims. The information was current at the time of publication. We will announce changes on the

Provider News Center and the Provider Engagement, Analytics & Reporting (PEAR) portal.Product namePayer information

for electronic claimsPaper claim mailing addressBilling provider

ISA-08GS-03

Keystone Health Plan EastIndependence

QCGKeystone Health Plan East POS

5470495056Claims Receipt Center

P.O. Box 211184

Eagan, MN 55121Valid and registered

NPI is

required.

Electronic (837P)

Loop 2010AA

NM108 = XX

NM109 = NPI #

Paper (CMS-1500)

NPI # - Box 33AQCHKeystone Health Plan East HMO

QCI

Keystone 65 HMO

Keystone 65 Focus Rx HMO

QCJKeystone Health Plan East ERISA POS

QCKKeystone 65 POS

QCLKeystone Health Plan East ERISA HMO

QHXႇ

QSPIBC HMO Proactive Small Group

QXJIBC HMO Proactive Individual - On Exchange

YXQ

Keystone HMO Platinum - On Exchange*

Keystone HMO Gold - On Exchange

Keystone HMO Silver Classic - On Exchange

Keystone HMO Silver Basic - On Exchange

Keystone HMO Bronze - On Exchange

Keystone HMO Gold Classic - On Exchange

YXRSmall Group POS - On Exchange*

YXW ႇPersonal Choice

Independence

WYXPersonal Choice EPO - HSA

5470454704Claims Receipt Center

P.O. Box 211184

Eagan, MN 55121YXFPersonal Choice PPO

YXK

Personal Choice 65

SM PPO

Personal Choice 65 Prime Rx PPO

Payer ID provider number reference — Professional

Rev. April 2023

2

Product namePayer information

for electronic claimsPaper claim mailing addressBilling provider

ISA-08GS-03

Personal Choice

(continued)Independence

Valid and registered

NPI is

required.

Electronic (837P)

Loop 2010AA

NM108 = XX

NM109 = NPI #

Paper (CMS-1500)

NPI # - Box 33AYXO

5470454704Claims Receipt Center

P.O. Box 211184

Eagan, MN 55121ႇ

YXP

Personal Choice PPO Platinum - On Exchange*

Personal Choice PPO Gold - On Exchange

Personal Choice PPO Gold Classic - On Exchange

Personal Choice PPO Silver - On Exchange

Personal Choice PPO Bronze - On Exchange

Personal Choice PPO Bronze Reserve - On Exchange*

YXUSmall Group PPO - On Exchange*

YXX Personal Choice EPO Catastrophic, Bronze Basic, Gold*, Bronze Reserve, Platinum*, and Silver Reserve* - On Exchange YXY Personal Choice EPO Catastrophic, Bronze Basic, Gold*,

Bronze Reserve, Platinum*, Silver Reserve*,

BlueCard

Independence

PPO Professional Blue Cross or Blue Shield member ID card with Medicare Advantage PPO Blue Cross or Blue Shield member ID card

5470454704Claims Receipt Center

P.O. Box 211184

Eagan, MN 55121

Payer ID provider number reference — Professional

Rev. April 2023

3

Product namePayer information

for electronic claimsPaper claim mailing addressBilling provider

ISA-08GS-03

BlueHPN

Independence

All BlueHPN Prefixes

the Blue High Performance Network name and the "BlueHPN in a suitcase" logo ID Card Back: A disclaimer indicates that the member has

5470454704Claims Receipt Center

P.O. Box 211184

Eagan, MN 55121

Valid and registered

NPI is

required.

Electronic (837P)

Loop 2010AA

NM108 = XX

NM109 = NPI #

Paper (CMS-1500)

NPI

Box 33A

Blue Cross

Independence

QMOMedigapFreedom5470454704Claims Receipt Center

P.O. Box 211184

Eagan, MN 55121

Blue Shield

Highmark

QCA

QCCTraditional Blue Cross

Blue Shield

Concurrent Major Medical

5477154771Highmark Blue Shield

P.O. Box 890062

Camp Hill, PA 17089-0062QCESecurity 65

, 65 Special, and MedigapSecurity QCN

QCO Comprehensive Major Medical (CMM)

Blue Cross Indemnity

QCR

Medigap, Blue Cross only

Federal Blue CrossHighmark

R followed by 8 numeric charactersFederal Employee Program (FEP) member ID starts with an "R"5477154771Highmark Blue Shield

P.O. Box 890062

Camp Hill, PA 17089-0062

Payer ID provider number reference — Professional

Rev. April 2023

4 When treating non-Independence members, professional claims for Highmark Blue Shield, Highmark Blue Cross Blue Shield of Delaware, Highmark BCBS of Western New York, Highmark BS Northeastern New York, and Highmark

Product namePayer information

for electronic claimsPaper claim mailing addressBilling provider

ISA-08GS-03

Third-party administratorsIndependence

Administrators

Valid and registered

NPI is

required.

Electronic (837I)

Loop 2010AA

NM108 = XX

NM109 = NPI #

Paper (UB-04)

NPI # - Box 56Independence Administrators

I ndependence Administrators logo on the ID card with

Independence Administrators

For additional claims information, visit

54704
TA720 or

54763Independence Administrators

c/o Processing Center

P.O. Box 21974

Eagan, MN 55121

Independence Administrators

Performance Network name and the "Blue HPN in a suitcase" logo ID card back: A disclaimer indicates that the member has

Independence Administrators

For additional claims information, visit .

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