Payer ID Grid - Facility - Independence Blue Cross
Rev. 1/2015 Payer ID provider number reference — Facility As of January 1, 2015, most Independence Blue Cross (Independence) membership is on our new operating platform. Upon migration, many products were assigned a new alpha prefix and members were sent new ID cards. Please note that this document lists alpha prefixes for the new platform only; non-migrated alpha prefixes are listed in parentheses, where applicable. Note: This grid was current at the time of publication but is subject to change. Look for announcements about revised payer ID grids in Partners in Health UpdateSM, on Independence NaviNet® Plan Central, and on our Provider News Center. Alpha prefix Product name Keystone Health Plan East (KHPE) QCG (previously YXG) Payer information ISA-08 GS-03 Independence Emdeon payer information* Paper claim mailing address 12X25 Keystone Health Plan East P.O. Box 69353 Harrisburg, PA 17106-9353 Billing provider KHPE POS QCH (previously YXH) KHPE HMO QCH Small Group HMO Bronze Basic – Off Exchange QCI (previously YXI) KHPE Medicare HMO QCJ (previously YXJ) KHPE ERISA POS QCK (previously YXC) KHPE Medicare POS QCL (previously YXE) KHPE ERISA HMO Keystone HMO Platinum – On Exchange YXQ Keystone HMO Gold and Gold Proactive – On Exchange Keystone HMO Silver and Silver Proactive – On Exchange 54704 95056 Keystone HMO Bronze – On Exchange YXR Valid and registered NPI is required. Electronic (837I) Loop 2010AA NM108 = XX NM109 = NPI # Paper (UB-04) NPI # – Box 56 Small Group/Shop POS – On Exchange Keystone HMO Platinum – Off Exchange YXW Keystone HMO Gold and Gold Proactive – Off Exchange Keystone HMO Silver and Silver Proactive – Off Exchange Keystone HMO Bronze – Off Exchange YXZ Small Group HMO – On Exchange Small Group HMO Bronze Basic – On Exchange Personal Choice® YXF (previously QCB) Personal Choice PPO YXK (previously QCM) Personal Choice 65SM PPO Independence Personal Choice PPO Platinum and Platinum Complete – Off Exchange Personal Choice PPO Gold – Off Exchange YXO Personal Choice PPO Silver and Silver Reserve – Off Exchange 54704 54704 12X26 Personal Choice Claims P.O. Box 69352 Harrisburg, PA 17106-9352 Personal Choice PPO Bronze and Bronze Reserve – Off Exchange Personal Choice PPO Catastrophic – Off Exchange Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association. 1 Rev. 1/2015 Payer ID provider number reference — Facility Alpha prefix Product name Payer information ISA-08 GS-03 Emdeon payer information* Paper claim mailing address 12X26 Personal Choice Claims P.O. Box 69352 Harrisburg, PA 17106-9352 Billing provider Personal Choice® (continued) Personal Choice PPO Platinum and Platinum Complete – On Exchange Personal Choice PPO Gold – On Exchange YXP Personal Choice PPO Silver and Silver Reserve – On Exchange Personal Choice PPO Bronze, Bronze Basic, and Bronze Reserve – On Exchange 54704 54704 Personal Choice PPO Catastrophic – On Exchange YXU Small Group PPO – On Exchange Account-specific National BlueCard® PPO ADQ, AEK, AGE, APQ, ARR, ASE, AUA, AUK, BAL, BPB, BRD, BWW, BYN, CBE, CDJ, CDQ, CDZ, CHC, COS, CQA, CQX, CUI, CZN, CZS, DAZ, DBO, DFB, DGR, DKV, DPO, DVU, DWU, EEN, EGD, EIZ, FFI, FQU, FSC, GCY, GEA, GEU, HAJ, HKZ, HXT, ICC, INW, IUR, IXP, IYC, KPY, KXH, LFS, LLH, LMS, LRC, LYW, MGL, MNF, NPP, NZK, OCR, OCZ, PAH, PBT, PDA, PSM, PTA, PUI, PXF, RAE, RID, RJG, RLA, ROO, ROQ, SDA, SEZ, SFU, SHQ, SKH, SQT, SZA, TFE, TMB, TMW, TQJ, TRX, TWS, UBF, UBL, UDS, UFN, UFP, UFT, UHF, ULB, UPB, UTR, WHV, WIQ, WIV, WQB Account-specific National BlueCard PPO 54704 54704 12X26 Personal Choice Claims Account-specific National BlueCard PPO P.O. Box 69352 Harrisburg, PA 17106-9352 Valid and registered NPI is required. Electronic (837I) Loop 2010AA NM108 = XX NM109 = NPI # Paper (UB-04) NPI # – Box 56 Blue Cross® QCA (previously QCD) Independence Highmark Traditional Blue Cross® Blue Shield® QCC (previously QCW) Concurrent Major Medical QCE (previously QCS) Security 65®, 65 Special, and MedigapSecurity QCN (previously QCT) Comprehensive Major Medical (CMM) QCO (previously YXD) Blue Cross Indemnity QCP Special CareSM† QCR (previously YXS) Medigap, Blue Cross only YXN Blue Cross, A Multi-State Plan – On Exchange 54704 54704 12X26 Independence Blue Cross P.O. Box 7516 Philadelphia, PA 19103 Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association. 2 Rev. 1/2015 Payer ID provider number reference — Facility Alpha prefix Product name BlueCard® AMS, ATS BlueCard – Albertsons NJP BlueCard – New Jersey Plus (NJ State employee) UPP BlueCard – United Parcel (enrollment 363 or 378) UPP BlueCard – United Parcel (362 or blank suitcase) YHF BlueCard – New Jersey Plus (Horizon BCBS NJ employee) Not applicable BlueCard out-of-area Blue Cross or Blue Shield member ID card with a suitcase and a prefix not defined previously BlueCard® Not applicable Medicare Advantage PPO out-of-area Blue Cross or Blue Shield member ID card with “MA PPO” in a suitcase and a prefix not defined previously Federal Blue Cross R followed by 8 numeric characters Federal Employee Program (FEP) member ID starts with an “R” Third-party administrators CNS, DQU, DVK, EQJ, FJM, FYP, GJF, GJJ, GKV, GSN, IKE, IKF, IKM, IXU, LUF, MFL, MGA, MGG, OBW, OCQ, OMJ, OPY, PBX, PRP, PUQ, SNC, UJX, WUF, YXA, YXB, YXL, YXT Payer information ISA-08 GS-03 Highmark 54704 54704 Emdeon payer information* Paper claim mailing address 12X26 Highmark Blue Shield P.O. Box 890062 Camp Hill, PA 17089-0062 Valid and registered NPI is required. Independence 54704 54704 12X26 Independence Blue Cross P.O. Box 7516 Philadelphia, PA 19103 12X26 Federal Blue Cross P.O. Box 7516 Philadelphia, PA 19103 54763 Independence Administrators P.O. Box 21974 Eagan, MN 55121 Highmark 54704 54704 Electronic (837I) Loop 2010AA NM108 = XX NM109 = NPI # Paper (UB-04) NPI # – Box 56 Independence Administrators Independence Administrators For additional claims information, visit www.ibxtpa.com/providers. Billing provider 54704 TA720 *For use only by those who use Emdeon as their clearinghouse. Clearinghouses may update submission rules, so always confirm specific submission requirements with your clearinghouse. † This product is no longer offered. Out-of-state providers should submit BlueCard-related claims to their local plan. For questions regarding this information, please call the eBusiness Help Desk at 215-241-2305. NaviNet is a registered trademark of NaviNet, Inc., an independent company. Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association. 3
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