List of Automatic Crossover Trading Partner (Insurers) In ...

[Pages:24]List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process

Supplemental Payers and Insurers (Trading Partners)

Trading Partner

GROUP HEALTH, INC. (GHI)- HMO - SUPPLEMENTAL WELLMARK BCBS (FEP) WELLMARK BCBS OF IOWA (FEP) WELLMARK BCBS OF IOWA (FEP) WELLMARK BCBS OF IOWA (FEP) THE REGENCE GROUP (IDAHO-FEHBP) THE REGENCE GROUP (BLUE SHIELD--FEHBP) THE REGENCE GROUP (UTAH--FEHBP) THE REGENCE GROUP (OREGON--FEHBP) MONUMENTAL LIFE INSURANCE CO. (FORMERLY UNDER AEGON) - SUPPLEMENTAL CONNECTICUT GENERAL LIFE INSURANCE CO. (CIGNA) HORIZON BCBS OF NJ - SUPPLEMENTAL WELLMARK BCBS OF IOWA WELLMARK BCBS OF SD WELLMARK BCBS OF SD WISCONSIN PHYSICIAN SERVICES - COMMERCIAL WISCONSIN PHYSICIAN SERVICES - COMMERCIAL BCBS OF MICHIGAN BCBS OF ALABAMA - SUPPLEMENTAL BCBS OF SOUTH CAROLINA - SUPPLEMENTAL HIGHMARK, INC. - SUPPLEMENTAL PART B & DMERC HIGHMARK, INC. - SUPPLEMENTAL PART A ONLY GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- SUPPLEMENTAL BCBS OF MICHIGAN AETNA, INC. BCBS OF MICHIGAN BCBS OF MICHIGAN - BCN (BLUE CARE NETWORK) BLUE CROSS AND BLUE OF MISSISSIPPI - SUPPLEMENTAL BLUE CROSS AND BLUE OF MISSISSIPPI - SUPPLEMENTAL BLUE CROSS OF NORTHEASTERN PA - SUPPLEMENTAL (PART A ONLY) BLUE CROSS OF NORTHEASTERN PA - SUPPLEMENTAL (PART A ONLY) METROPOLITAN HEALTH PLAN - SUPPLEMENTAL PRIMEWEST HEALTH PLAN - SUPPLEMENTAL PRIMEWEST HEALTH PLAN - SUPPLEMENTAL

Identification Number(s)

00002 00004 00005 00005 00006 00009 00010 00011 00012 00017 00018 00019 00020 00021 00023 00025 00026 00027 00028 00029 00030 00031 00032 00033 00034 00035 00036 00037 00041 00042 00044 00055 00060 00061 00062 00067 00068 00069 00070 00072 00073 00073

Customer Contact

Customer Service Customer/Provider Services Provider Services Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer/Provider Services Customer/Provider Services Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer/Provider Services Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Cathy Stitzer Cathy Stitzer Bonnie Hays Provider Services Mary Winter

Updated: 01/31/2015

Contact Number

877-244-4466 800-524-9242 800-524-9242 800-373-5348 800-524-9242 800-343-8915 800-343-8915 800-343-8915 800-343-8915 800-854-0186 800-244-6224 800-624-1110 800-524-9242 800-524-9242 800-524-9242 888-253-2694 888-253-2694 313-225-9000 205-988-2200 800-760-9290 800-345-3806 800-345-3806 212-501-4444 212-501-4444 212-501-4444 212-501-4444 212-501-4444 212-501-4444 888-762-2189 888-762-2189 888-762-2189 313-225-9000 860-273-0123 313-225-9000 800-450-3680 800-257-5825 800-257-5825 570-200-4540 570-200-4540 612-543-3338 866-431-0802 320-335-5239

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Trading Partner TRIPLE S, INC. - SUPPLEMENTAL CAREFIRST OF DC - PART A ONLY CAREFIRST OF DC - PART B ONLY BCBS OF NORTH DAKOTA BCBS OF WYOMING - SUPPLEMENTAL (PART B & DMERC) BCBS OF NORTH DAKOTA MEDICAL MUTUAL OF OHIO - SUPPLEMENTAL BCBS OF TENNESSEE - SUPPLEMENTAL UNITED HEALTH CARE-UNET - SUPPLEMENTAL UNITED HEALTH CARE - SUPPLEMENTAL GROUP HEALTH COOPERATIVE - SUPPLEMENTAL BLUE CROSS AND BLUE SHIELD OF MINNESOTA - SUPPLEMENTAL BLUE CROSS AND BLUE SHIELD OF MINNESOTA - SUPPLEMENTAL BLUE CROSS AND BLUE SHIELD OF MINNESOTA - SUPPLEMENTAL EMPIRE BCBS - SUPPLEMENTAL EMPIRE BCBS - SUPPLEMENTAL BCBS OF KANSAS - SUPPLEMENTAL KPS HEALTH PLANS- SUPPLEMENTAL ANTHEM BCBS OF CT - SUPPLEMENTAL ANTHEM BCBS OF NH - SUPPLEMENTAL ANTHEM BCBS OF ME - SUPPLEMENTAL BCBS OF LOUISIANA - SUPPLEMENTAL NEW JERSEY CARPENTERS HEALTH FUND - SUPPLEMENTAL MAYO MEDICAL SYSTEMS, INC. (MMSI) - SUPPLEMENTAL WEA INSURANCE COMPANY - SUPPLEMENTAL CAREFIRST OF DC - SUPPLEMENTAL CAREFIRST OF DC - SUPPLEMENTAL CAREFIRST OF MD - SUPPLEMENTAL EMPIRE BCBS - SUPPLEMENTAL EMPIRE BCBS - SUPPLEMENTAL CARPENTERS TRUST OF WESTERN WASHINGTON BLUE SHIELD OF CALIFORNIA - SUPPLEMENTAL BCBS OF NORTH CAROLINA CAPITAL BLUE CROSS - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BLUE CROSS AND BLUE SHIELD OF DELAWARE - SUPPLEMENTAL

Updated: 01/31/2015

Coordination of Benefits Agreement National Crossover Process

Supplemental Payers and Insurers (Trading Partners)

Identification Number(s)

00074 00075 00076 00077 00078 00079 00080 00081 00082 00083 00087 00088 00089 00090 00091 00092 00093 00094 00095 00096 00097 00099 00102 00103 00104 00105 00106 00107 00108 00109 00110 00111 00112 00113 00114 00114 00114 00115 00115 00115 00116 00118

Customer Contact

Jeannette Irizarry Velez Provider Services Provider Services Gina Bercherl Amber Zowada Gina Bercherl Sue Robinson Customer Service Customer Service Customer Service Kim Mitchell Customer Service Customer Service Customer Service Annie Pressley-Mitchell Annie Pressley-Mitchell Customer Service Teresa Hiagh-Braget Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Customer Service Rachel Corradi Customer Service Sheryl Shilbauer Part A only Part B only Part B only Customer Service Customer Service Min-Sug (Darren) Kong Tammy Rutters eSolutions Help Desk Nancy Herman Buffalo (CNY West) Albany Region II Albany (CNY East) Traditional Member Managed Care Member Provider Services Melissa Deboth Customer Service

Contact Number

787-749-4949 410-998-4599 410-998-4599 701-277-2081 307-432-2743 701-277-2081 800-700-2583 800-553-8158 866-633-2446 866-633-2446 509-241-7045 800-531-6686 800-531-6686 800-531-6686 404-848-2185 404-848-2185 800-432-3990 360-478-2635 404-848-2185 404-848-2185 404-848-2185 800-392-4089 732-417-3900 ext. 272 800-635-6671 608-276-4000 410-998-4599 410-998-4599 410-998-4599 800-435-1385 800-435-1386 206-441-6514 530-351-6019 888-333-8594 717-541-6274 866-638-9011 800-945-0566 800-856-0480 800-888-1238 800-459-7587 800-444-4552 716-887-8443 302-429-0260

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process

Supplemental Payers and Insurers (Trading Partners)

Trading Partner HEALTH ALLIANCE PLAN OF MICHIGAN - SUPPLEMENTAL BCBS OF ARIZONA - SUPPLEMENTAL MARSH AFFINITY GROUP SERVICES ALLEGIANCE BENEFIT PLAN MANAGEMENT EMPLOYEE BENEFIT MANAGEMENT CARE - SUPPLEMENTAL ANTHEM BCBS-CENTRAL (FACETS) -IN, KY, OH - SUPPLEMENTAL HEALTH DESIGN PLUS ANTHEM NATIONAL BCBS OF OHIO - SUPPLEMENTAL ANTHEM NATIONAL BCBS OF KENTUCKY - SUPPLEMENTAL ANTHEM NATIONAL BCBS OF INDIANA - SUPPLEMENTAL ANTHEM BCBS OF ME - SUPPLEMENTAL ANTHEM BCBS OF NH - SUPPLEMENTAL ANTHEM BCBS OF CT - SUPPLEMENTAL

Identification Number(s) 00119 00122 00123 00124 00127 00128 00130 00131 00134 00136 00139 00140 00141

Customer Contact Kenny Dodson Lisa Peppers

Customer Service Customer Service Customer Service Customer Service Annie Pressley-Mitchell Customer Service Customer Service Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell

EXCELLUS HEALTH PLAN (INCLUDING BCBS OF UTICA, SYRACUSE, & ROCHESTER) - SUPPLEMENTAL

EXCELLUS HEALTH PLAN (INCLUDING BCBS OF UTICA, SYRACUSE, & ROCHESTER) - SUPPLEMENTAL

EXCELLUS HEALTH PLAN (INCLUDING BCBS OF UTICA, SYRACUSE, & ROCHESTER) - SUPPLEMENTAL ANTHEM BCBS OF VIRGINIA - SUPPLEMENTAL ODS HEALTH PLANS, INC. - SUPPLEMENTAL ARKANSAS BCBS - SUPPLEMENTAL BCBS OF NORTH CAROLINA ARKANSAS BCBS (HEALTH ADVANTAGE) - SUPPLEMENTAL NATIONWIDE HEALTH PLANS - SUPPLEMENTAL PITTMAN & ASSOCIATES, INC. - SUPPLEMENTAL HEALTH ALLIANCE MEDICAL PLANS - SUPPLEMENTAL GRAPHIC COMMUNICATIONS NAT'L ANTHEM BCBS OF NEVADA ANTHEM BCBS OF COLORADO BLUE CROSS OF CALIFORNIA - SUPPLEMENTAL UNICARE LIFE & HEALTH INSURANCE COMPANY - SUPPLEMENTAL HEALTHNET, INC-- CA -SUPPLEMENTAL INSURANCE PROGRAMMERS INC. RESERVE NATIONAL INSURANCE CO AMA INSURANCE AGENCY, INC. - SUPPLEMENTAL BC OF IDAHO - SUPPLEMENTAL BC OF IDAHO - SUPPLEMENTAL ALLIED BENEFIT SYSTEMS, INC - SUPPLEMENTAL ALLIED BENEFIT SYSTEMS, INC - SUPPLEMENTAL NGS AMERICAN - SUPPLEMENTAL HIGHMARK WEST VIRGINIA

00145 00146

00147

00148 00150 00151 00152 00153 00154 00156 00157 00160 00166 00168 00170 00171 00173 00180 00182 00183 00184 00185 00188 00188 00189 00190

Carol Bump Jill Kohler

Jill Kohler

Part A only EDI Department Angela Winston eSolutions Help Desk Dee McKee Customer Service Andy Glankler Cindy Cargo Teresa Bauer Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Customer Service Amy Cook Reta Weaver Customer Service Customer Service Customer Service Outside IL IL Resident Customer Service Customer Service

Updated: 01/31/2015

Contact Number 248-443-2036 602-864-4018

406-721-2222 800-993-3262 866-649-2037 800-549-9114 404-848-3185 800-880-2583 317-287-5000 404-848-3185 404-848-3185 404-848-3185

315-671-6807 315-272-1210

315-272-1210

800-451-0361 800-852-5195 501-210-2074 888-333-8594 501-212-8520 877-234-2727 901-473-3344 217-383-8208 412-201-2242 404-848-2185 404-848-2185 404-848-2185 404-848-2185 800-641-7761 203-269-7741 800-654-9106 800-458-5736 866-482-2253 866-482-2253 800-288-2078 312-906-8080 800-521-1555 800-543-7822

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process

Supplemental Payers and Insurers (Trading Partners)

Trading Partner HIGHMARK WEST VIRGINIA UMR PENNSYLVANIA EMPLOYEE BENEFIT TRUST FUND (PEBTF) - SUPPLEMENTAL PENNSYLVANIA EMPLOYEE BENEFIT TRUST FUND (PEBTF) - SUPPLEMENTAL PREMERA BLUE CROSS - SUPPLEMENTAL POMCO, INC. - SUPPLEMENTAL BCBS OF MASS HEALTHSMART BCBS OF VERMONT - SUPPLEMENTAL OXFORD HEALTH - SUPPLEMENTAL UNITED HEALTH CARE- COSMOS - SUPPLEMENTAL C & R CONSULTING - SUPPLEMENTAL CORESOURCE, INC. - SUPPLEMENTAL CORESOURCE, INC. - SUPPLEMENTAL CORESOURCE, INC. - SUPPLEMENTAL BCBS OF KANSAS CITY BCBS OF RHODE ISLAND UNITED HEALTHCARE (SUPPLEMENTAL) MERITAIN HEALTH, INC. ASURIS REGENCE BLUESHIELD OF UTAH REGENCE BLUESHIELD REGENCE BCBS OF OREGON REGENCE BLUESHIELD OF IDAHO , INC. - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- SUPPLEMENTAL KIDNEY DISEASE PROGRAM OF MARYLAND - SUPPLEMENTAL AMALGAMATED LIFE/ALICARE - SUPPLEMENTAL HUMANA, INC. - SUPPLEMENTAL JP FARLEY BCBS OF MONTANA KEY BENEFITS ADMINISTRATORS - SUPPLEMENTAL COMPREHENSIVE BENEFITS CONSULTANTS (A.K.A. "FEDERATED ALLIED RETIREE ASSOCIATION")SUPPLEMENTAL UCARE MINNESOTA - SUPPLEMENTAL UCARE MINNESOTA - SUPPLEMENTAL C & O EMPLOYEE HOSPITAL - SUPPLEMENTAL BCBS OF NORTH CAROLINA PIPE FITTERS WELFARE FUND CONNECTICUT GENERAL LIFE INSURANCE CO. (CIGNA)

Updated: 01/31/2015

Identification Number(s)

00191 00192 00208 00208 00209 00210 00212 00214 00217 00220 00224 00226 00229 00229 00229 00232 00236 00237 00240 00246 00249 00250 00251 00252 00253 00254 00255 00256 00259 00267 00268 00280 00281 00282 00288

Customer Contact Customer Service Customer Service Rest of U.S. In Pennsylvania Customer Service Vivie Prichard Customer Service

Chantal Parent Customer Service Stewart McGehee C&R Customer One Beacon Ins Grp Crompton Corp All others Kathy Currey Customer Service Stewart McGehee Customer Service Rebecca Thorn Rebecca Thorn Rebecca Thorn Rebecca Thorn Rebecca Thorn Customer Service Customer Service Customer Service Customer Service Carol Manning Customer Service Customer Service Amanda Smolka Teha Hatfield Brooke Currence Lorraine Piazza

00292 00292 00295 00298 00299 00300

Provider Customer Service Member Assistance Anna Brooks ESolutions Help Desk

Customer Service

Contact Number 800-543-7822 800-826-9781 800-522-7279 717-565-7410 800-722-1471 800-830-2528 800-258-2226

802-371-3611 888-201-4133 336-540-7563 212-819-0792 866-889-7286 866-318 7173 800-223-3943 816-395-3877 800-267-0439. 336-540-7563 800-548-2041 503-375-4341 503-375-4341 503-375-4341 503-375-4341 503-375-4344 817-878-3300 888-762-2189 888-762-2189 888-762-2189 410-767-5004 212-539-5111 866-427-7478 440-250-4316 406-437-6496 803-396-4665 631-249-0500

888-531-1493 877-523-1515 540-862-5728 1-888-333-8594

800-244-6224

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process

Supplemental Payers and Insurers (Trading Partners)

Trading Partner PLUMBER LOCAL 130 UA NATIONAL ELEVATOR INDUSTRY HEALTH BE BCBS OF NORTH CAROLINA ANTHEM BCBS OF VIRGINIA - SUPPLEMENTAL THE LOOMIS COMPANY BCBS OF WYOMING -(PART A) WEB TPA SECURITY HEALTH PLAN OF WI, INC. HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF OK (OTHER A ONLY) HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF OK (OTHER B ONLY) CAPITOL DISTRICT PHYSICIANS' HEALTH PLAN WEBTPA EMPLOYER SERVICES RMSCO INC TIC ? BAC LOCAL UNION 15 W.F. TIC ? IBEW LOCAL 117 HEALTH W.F. TIC ? IBEW LOCAL 461 WELFARE FUND TIC ? UFCW LOCAL 400 HEALTH W.F. TIC ? ELECTRICAL WORKERS FUND BLUE CROSS OF NORTHEASTERN PA BLUE CROSS OF NORTHEASTERN PA BLUE CROSS OF NORTHEASTERN PA BLUE CARE COOPERATIVE PLUMBERS' AND PIPEFITTERS' WELFARE FUND DANA NON UNION RETIREE VEBA TRUST BLUE CROSS OF NORTHEASTERN PA G.M.P. - EMPLOYERS RETIREE TRUST MEDICA (PART B ONLY) MEDICA (PART A ONLY) UMR ONALASKA CONNECTICUT GENERAL LIFE INSURANCE CO. VANTAGE HEALTH PLAN, INC. BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA AVMED HEALTH PLANS PIPELINE INDUSTRY BENEFIT FUND THE WILLIAM C. EARHART CO., INC MID CENTRAL OPERATING ENGINEERS HEALTH & WELFARE FUND SOUTHWEST LIFE & HEALTH INS. CO. FIRSTCARE

Updated: 01/31/2015

Identification Number(s)

00304 00305 00306 00308 00310 00312 00313 00314 00317 00318 00321 00322 00323 00326 00328 00329 00331 00332 00333 00334 00335 00341 00343 00352 00353 00354 00360 00361 00362 00364 00365 00366 00367 00368 00369 00370 00371 00372 00374 00375 00377 00378

Customer Contact

ESolutions Help Desk Michael Bristoe

Amber Zowada Lisa Smith Shelia Nelson-Seybold Customer Service Customer Service Brian Freer Lisa Smith Jen Springler Michelle Cockerham Amy Pierce Susan Esterhai Linda Jividen Jackie Neible Cathy Stitzer Cathy Stitzer Cathy Stitzer Cathy Stitzer Nancy Winer Lorraine Piazza Cathy Stitzer Amy Thomas Stephanie Kelly Stephanie Kelly Wendy Wiggert Customer Service Provider Relations Customer Service Customer Service Customer Service Customer Service Customer Service Luis Aranguren Claims Supervisor Pam Fleischman Katricia Helton Melinda Rodriguez Melinda Rodriguez

Contact Number

1-888-333-8594 502-727-7280

307-432-2743 469-417-1854 715-221-9623 888-762-2189 888-762-2189 518-6413820 469-417-1854 315-448-9001 913-236-5490 877-423-9117 866-461-4239 303-343-7682 317-923-4577 570-200-4540 570-200-4540 570-200-4540 570-200-4540 314-355-1000 631-249-0500 570-200-4540 239-936-6242 952-992-2582 952-992-2582 608-783-8523 800-244-6224 318-361-0900 X 112 800-531-6686 800-531-6686 800-531-6686 800-531-6686 800-531-6686 305-671-0193 918-280-4800 503-331-8209 812-232-4384 806-784-4378 806-784-4378

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Trading Partner WABASH MEMORIAL HOSPITAL ASSOC. AMERICAN BENEFIT CORPORATION TIC ? NECA IBEW LOCAL 364 HEALTH RIGHT CHOICE BENEFIT ADMIN. BCBS OF NEBRASKA BCBS OF NEBRASKA HP ADMINISTATIVE SERVICES, LLC ADC 1 WELFARE FUND BLUE SHIELD OF CALIFORNIA - SFEW IE SCHAFFER & CO C & R CONSULTING ARKANSAS BCBS COVENTRY NATIONAL ACCOUNTS EMBLEMHEALTH SVC CO. LLC - VYTRA EMBLEMHEALTH SVC COMPANY, LLC - HIP M.C.D.C HEALTH FUND PLUMBERS & PIPEFITTERS LOCAL 630 OE LOCAL 139 HBF PIPE TRADES INDUSTRY H&W PLAN HEALTHNET OF ARIZONA, INC. HEALTHNET OF THE NORTHEAST, INC. C&R CONSULTING BLUE SHIELD OF CALIFORNIA SCPT HEALTH & WELFARE FUND LIBERTY NATIONAL LIFE INSURANCE CO. - GMS GUNDERSEN LUTHERAN HEALTH PLAN SENTARA HEALTH PLANS INC. INDIANA LABORERS WELFARE FUND INDIANA LABORERS WELFARE FUND AMERICAN BENEFIT CORPORATION BCBS OF LOUISIANA HEALTH CARE SERVICE CORP, BCBS HEALTH CARE SERVICE CORP, BCBS KAISER FOUNDATION HEALTH PLAN INDEPENDENCE BLUE CROSS OPERATING ENGINEERS H&W FUND TIC-NECA IBEW LCL 150 FRINGE BF UMR SAN ANTONIO FABIAN & BYRN LLC DELTA HEALTH SERVICES, INC.

Updated: 01/31/2015

Coordination of Benefits Agreement National Crossover Process

Supplemental Payers and Insurers (Trading Partners)

Identification Number(s) 00379 00380 00386 00387 00388 00392 00402 00406 00407 00411 00413 00417 00420 00422 00423 00425 00426 00427 00428 00429 00430 00431 00433 00434 00435 00436 00438 00439 00440 00445 00455 00456 00457 00459 00460 00462 00463 00465 00467 00470

Customer Contact Debby Kunze Linda Sites Medical Claims Department Customer Service Right Choice Customer Service Center Customer Service Center Jenny Ray Yolanda Alzati Lisa Schultz Terri Trasatti

Angela Winston Customer Service Robyn Callahan Robyn Callahan Sandra Belot Amanda Ratcliff Annette Kusick Pam Lewis Healthnet Provider Service Healthnet Provider Service

Tammy Rutters Marcus Chin Customer Service Department Ann Kiel Todd Kelly Melissa Wade Melissa Wade Linda Sites Customer Service Blue Cross Blue Shield Blue Cross Blue Shield Member Service Sharelle Bond Elisabeth Schaefer Jan Smith Customer Service Talisha Douglas Christine Dugger-Praet

Contact Number 217-429-5246 304-525-0331 800-228-0048 800-365-9036 800-991-7392 800-991-7392 405-416-1514 630-617-8630 415-263-3670 609-883-6688

501-210-2074 800-937-6824 631-577-5091 631-577-5091 262-970-5790 954-266-6322 262-549-9190 812-877-2581 800-977-7522 800-438-7886

530-351-6019 213-385-6161 972-529-5085 608-775-8070 757-552-7237 812-238-2551 812-238-2551 304-525-0331 800-392-4089 888-762-2189 888-762-2189 800-777-7902 215-241-9227 626-356-3560 877-478-4542 800-368-3653 973-228-4200 559-228-4185

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Trading Partner EXCELLUS HEALTH PLANS HARRINGTON HEALTH SERVICES, INC. NECA FAMILY MEDICAL CARE PLAN BLUE CROSS BLUE SHIELD OF GA KCSUP BLUE CROSS BLUE SHIELD OF GA KCSUP EIGHTH DISTRICT ELECTRICAL BENEF MEDICAL ASSOC HEALTH PLAN INC WEST MICH. PLUMBERS, FITTERS NATIONAL BCBS GEORGIA DESERET MUTUAL WISCONSIN PHYSICIANS SERVICE WISCONSIN PHYSICIANS SERVICE IAHFI LOCAL 17 WELFARE FUND HEALTHLINK HMO, INC INDEPENDENCE BLUE CROSS PEHP HEALTH CARE SERVICE CORPORATION HEALTH CARE SERVICE CORPORATION WELLMARK BCBS OF SD WELLMARK BCBS OF IA MIDWEST OPERATING ENGINEERS HEALTH NEW YORK ISG NEVADA ISG MAINE ISG WISSONSIN ISG KENTUCKY ISG VIRGINIA ISG NEW HAMPSHIRE ISG MISSOURI ISG OHIO ISG CALIFORNIA ISG COLORADO ISG CONNECTICUT ISG INDIANA ISG CONNECTICUT WGS INDIANA WGS KENTUCKY WGS MISSOURI WGS NEW YORK WGS OHIO WGS VIRGINIA WGS WISCONSIN WGS

Updated: 01/31/2015

Coordination of Benefits Agreement National Crossover Process

Supplemental Payers and Insurers (Trading Partners)

Identification Number(s)

00472 00473 00474 00475 00476 00478 00479 00484 00485 00486 00493 00494 00495 00498 00500 00501 00502 00503 00506 00507 00508 00509 00510 00511 00512 00513 00514 00515 00516 00517 00518 00519 00520 00521 00522 00523 00524 00526 00528 00529 00530 00531

Customer Contact

Michael Sirni Customer Service Vicki Burrows Annie Pressley-Mitchell Michael Bristoe Mary Kemp Laura Boge Customer Service Annie Pressley-Mitchell Donna Mcreavy Kit Lee Kit Lee William Mangin Karen Gotsch Sharelle Bond Josie Hall Blue Cross/Blue Shield Blue Cross/Blue Shield Customer/Provider Services Customer/Provider Services Barbara Glembin Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell

Contact Number

315-272-0121 800-216-2166 877-937-9602 404-848-2185 502-727-7280 801-973-1001 563-556-8070 219-769-6944 404-848-2185 801-578-5621 608-226-3369 608-226-3369 708-468-8000 314-925-6166 215-241-9227 801-366-7519 888-762-2189 888-762-2189 800-524-9242 800-524-9242 708-579-6603 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677 770-401-4677

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process

Supplemental Payers and Insurers (Trading Partners)

Trading Partner MONUMENTAL LIFE INSURANCE CO. AARP/UNITED HEALTH CARE (DOING BUSINESS AS "UNITED HEALTH GROUP") MEDIGAP WELLMARK BCBS OF SD WELLMARK BCBS OF IA MONUMENTAL LIFE INSURANCE CO. (FORMERLY UNDER AEGON) MEDIGAP HORIZON BCBS OF NJ - MEDIGAP BCBS OF MICHIGAN BCBS OF SC HIGHMARK, INC. - MEDIGAP PAT B & DMERC HIGHMARK, INC. - MEDIGAP PART A ONLY GROUP HEALTH, INC. (GHI) PPO - MEDIGAP GROUP HEALTH, INC. (GHI) PPO - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- MEDIGAP LIBERTY NATIONAL LIFE INSURANCE CO. (AFFILIATED WITH TORCHMARK) LIBERTY NATIONAL LIFE INSURANCE CO. (AFFILIATED WITH TORCHMARK) GLOBAL LIFE & ACCIDENT INSURANCE CO. (AFFILIATED WITH TORCHMARK) AMERICAN INCOME LIFE INSURANCE CO. (AFFILIATED WITH TORCHMARK) UNITED AMERICAN INSURANCE COMPANY (TORCHMARK) - MEDIGAP FIRST UNITED AMERICAN LIFE INS. CO. EQUITABLE LIFE & CASUALITY INS. CO. BLUE CROSS AND BLUE OF MISSISSIPPI - MEDIGAP BLUE CROSS OF NORTHEASTERN PA - MEDIGAP (PART A ONLY) BLUE CROSS OF NORTHEASTERN PA - MEDIGAP (PART A ONLY) TRIPLE S, INC. - MEDIGAP BCBS OF WYOMING - MEDIGAP (PART A, B, DMERC) BCBS OF NORTH DAKOTA BCBS OF TENNESSEE - MEDIGAP UNITED COMMERCIAL TRAVELERS - MEDIGAP STANDARD LIFE ACCIDENT INSURANCE COMPANY (SLA) - MEDIGAP SLA/AMERICAN NATIONAL LIFE INSURANCE CO. (ANICO) OF TEXAS - MEDIGAP LOYALAM/UNITEDTEACH/GREATAMLIFE GUARANTEE TRUST LIFE INSURANCE COMPANY - MEDIGAP (DMERC IN ALL STATES AND PART-B IN ALL STATES EXCEPT MN AND WI) EMPIRE BCBS - MEDIGAP BLUE CROSS AND BLUE SHIELD OF MINNESOTA - MEDIGAP BLUE CROSS AND BLUE SHIELD OF MINNESOTA - MEDIGAP BLUE CROSS AND BLUE SHIELD OF MINNESOTA - MEDIGAP

Identification Number(s) 30000 30002 30003 30004 30006 30013 30015 30016 30017 30018 30019 30020 30023 30024 30025 30026 30027 30028 30029 30030 30032 30033 30034 30035 30036 30039 30040 30041 30042 30045 30046 30047 30048 30051 30052 30054 30055

Customer Contact Christine Turman Customer Service Customer/Provider Services Provider Services Christine Turman Customer Service Customer Service Judith Murray Customer Service Customer Service Geraldine Holmes Geraldine Holmes Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Laura Sarle Customer Service Cathy Stitzer Cathy Stitzer Jeannette Irizarry Velez Amber Zowada Gina Bercherl Venessa Marsh Doris Gunn Jill Davis Jill Davis Customer Service Mark Pytel

30056 30057 30058 30059

Annie Pressley-Mitchell MN only non-MN DMERC only

Updated: 01/31/2015

Contact Number 610-648-4894 800-523-5800 800-524-9242 800-524-9242 610-648-4894 800-624-1110 313-225-9000 803-264-3889 800-345-3806 800-345-3806 315-4342437 315-4342437 888-762-2189 888-762-2189 888-762-2189 888-762-2189 888-762-2189 888-762-2189 972-529-5085 972-529-5085 972-529-5085 972-529-5085 972-529-5085 972-529-5085 801-579-3464 800-257-5825 570-200-4540 570-200-4540 787-749-4949 307-432-2743 701-277-2081 423-535-4930 614-487-9680 281-538-4890 281-538-4890 866-459-4272 847-904-5375

404-848-2185 800-531-6686 800-531-6686 800-531-6686

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