Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.state.ma.us/dma

MASSHEALTH
TRANSMITTAL LETTER ALL-114
May 2003
TO:      All Providers Participating in MassHealth
FROM:      Douglas S. Brown, Acting Commissioner
RE:      All Provider Manuals (Revised Appendix C)

For members who have other insurance, the MassHealth Recipient Eligibility Verification System (REVS) reports the coverage-type, carrier code, and policy number of the insurance listed on file. Appendix C of all MassHealth provider manuals lists in numeric order by carrier code the name and address of the other insurance so that you can bill that insurance before billing MassHealth.
If you receive written evidence (for example, an explanation of benefits or a letter from an employer) that a member does not have the insurance identified on REVS, has different insurance than what is reported on REVS, or no longer has insurance coverage, please mail or fax the information to:
Division of Medical Assistance TPL Unit P.O. Box 9209 Boston, MA 02209 Fax: 617-357-7604
This letter transmits an updated Appendix C for all provider manuals. You can also view, print, or download Appendix C from the Division’s Web site at www.mass.gov/dma. The downloadable version of Appendix C is searchable, a significant advantage over the printed version. Other provider manual appendices and frequently requested materials are also available on our Web site.
Please Note: We will update Appendix C on our Web site as needed to keep it current. We do not send updates for Appendix C to providers unless requested. To receive a paper copy of the latest Appendix C, mail, fax, or e-mail your request to:
MassHealth Publications	Fax: 617-576-4487
P.O. Box 9101	E-mail: mapublications@unisys.com
Somerville, MA 02145
Please include your provider number, address, and telephone number with your request.

MASSHEALTH
TRANSMITTAL LETTER ALL-114 May 2003 Page 2
NEW MATERIAL
(The pages listed here contain new or revised language.)
All Provider Manuals
Pages C-1 through C-26
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
All Provider Manuals
Pages C-1 through C-36 — transmitted by Transmittal Letter ALL-103

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-1	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
THIRD-PARTY-LIABILITY CODES
Important Note: A searchable version of this appendix is also available on the Division’s Web site at www.mass.gov/dma. The Division will update Appendix C as needed. Paper copies of this appendix will not be mailed automatically, but can be requested by mailing, faxing, or e-mailing a request to:

MassHealth Publications P.O. Box 9101 Somerville, MA 02145

Fax: 617-576-4487
E-mail: mapublications@unisys.com

This appendix contains a list of third-party-liability (TPL) coverage-type codes and a numeric list of carrier codes, including carrier names and addresses. The MassHealth Recipient Eligibility Verification System (REVS) provides the TPL coverage-type and carrier codes for all applicable insurance coverage for a member. For members with a temporary MassHealth card, any applicable TPL coverage-type and carrier codes are printed on the card itself.
I.     THIRD-PARTY-LIABILITY COVERAGE-TYPE CODES
The following is a list of TPL coverage-type codes that identify the type of insurance a member has.

* If a member has dental, vision, or pharmacy coverage only, then the member can be enrolled in a managed care program.
1	Hospital Services
2	Comprehensive Indemnity
3	RESERVED
4	Medicare A
5	Medicare B
6	Medicare Supplement
7	Accident (non-auto)
8	Nursing Home Care
9	HMO without Mental Health
10	Hospital Confinement Indemnity
11	Health Maintenance Organization
12	Vision*
13	Dental*
14	Preferred Provider Organization
15	CHAMPUS or CHAMPVA
16	Medicare Part A Medigap
17	Pharmacy Coverage*
18	Pharmacy Coverage*
19	MassHealth MCO with Pharmacy
20	MassHealth MCO without Pharmacy
21	Special Populations with Pharmacy
22	RESERVED
23	MassHealth MCO Senior Plans with Pharmacy

24	MassHealth MCO Senior Plans without Pharmacy
25	MassHealth MCO/DSS Children with Special Needs with Pharmacy
26	Mental Health Services Program for Youth (MHSPY)
27	RESERVED
28	Community Care Connection (Disabled)
29	Community Care Connection (PPD)
30	Community Care Connection (Elderly)
31	Blue Master Health Plus
32	Hospice
33	Federal BC/BS Medigap Policies
34	PACE
35	Commercial Insurance without Mental Health
36	Pre-PACE
37	Senior Care Options
38	through 52 RESERVED
53	Hebrew Rehabilitation
54	Special Populations without Pharmacy
55	RESERVED
56	HMO Senior Plan
57	Long Term Care HMO Senior Plans
53	
II.    CARRIER CODES
The following is a list of carrier codes and the names and addresses of the insurance companies to which they refer.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-2	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
006-00	Board of Pension-Presbyterian Church, PO Box 13896, Philadelphia, PA 19101-3896
006-10	ChampVA, PO Box 65024, Denver, CO 80206-9024
027-00	Blue Cross Blue Shield of Massachusetts, PO Box 9197, North Quincy, MA 02171
027-02	Blue Cross Blue Shield of Massachusetts Medex, PO Box 9196, Boston, MA 02105
027-03	Blue Cross Blue Shield of Massachusetts Medex - Gold, PO Box 9196, Boston, MA 02105
027-25	Blue Cross Blue Shield Dental, PO Box 9157, North Quincy, MA 02171
027-26	HMO Blue Care Bluecare 65, PO Box 9201, North Quincy, MA 02171
027-33	Blus Cross Dental of Rhode Island, PO Box 219, Providence, RI 02901-0219
027-34	Blue Cross Blue Shield of Texas Dental, PO Box 660247, Dallas, TX 75266-0247
027-38	Blue Cross Blue Shield of Connecticut, 370 Bassett Rd, North Haven, CT 06473
027-45	Blue Cross Blue Shield of Maine, Two Gannett Dr, PO Box 9428, Portland, ME 04116
027-46	Anthem Blue Cross Blue Shield of New Hampshire, 3000 Goffs Fall Rd, Manchester, NH 03111
027-48	Blue Shield of Northeastern New York, PO Box 15013, Albany, NY 12212-5013
027-49	Empire Blue Cross Blue Shield of New York, PO Box 11800, Albany, NY 12211
027-50	Blue Cross Blue Shield of Western New York, 1901 Main St, PO Box 109, Buffalo, NY 14240
027-53	Empire Blue Cross Blue Shield, PO Box 5012, Middletown, NY 10940
027-58	Blue Cross Blue Shield of Rochester, 150 E Main St, Rochester, NY 14647
027-64	Empire Blue Cross Blue Shield, Verizon Dedicated Service, PO Box 5047, Middletown, NY
10943
027-67	Empire Blue Cross Blue Shield, PO Box 420, Murray Hill Station, New York, NY 10156
027-69	Empire Blue Cross Blue Shield, PO Box 5577, IBM Dedicated Service, New York, NY 10163
027-71	Empire Blue Cross Blue Shield, 622 Third Ave, New York, NY 10017
027-74	Empire Blue Cross Blue Shield, PO Box 399, Grand Central Station, New York, NY 10156
027-77	Empire Blue Cross Blue Shield, PO Box 170, New York, NY 10156
027-80	Blue Cross Blue Shield of Alabama, PO Box 360508, Birmingham, AL 35236-0508
028-00	Blue Cross Blue Shield of Michigan, 600 Lafayette E, Detroit, MI 48226
028-02	Empire Blue Cross Blue Shield, PO Box 5020, Middletown, NY 10940-9020
028-05	Blue Cross of California, 21555 Oxnard St, PO Box 70000, Woodland Hills, CA 91367
028-08	Carefirst Blue Cross Blue Shield, 550 12th St SW, Verizon, Washington, DC 20065-0001
028-09	Blue Cross Blue Shield of Delaware, One Brandywine Gateway, PO Box 1991, Wilmington, DE
19899
028-10	Highmark Blue Cross Blue Shield of PA, PO Box 1210, Pittsburg, PA 15230-1210
028-11	Blue Cross Blue Shield of Florida, 532 Riverside Ave, PO Box 1798, Jacksonville, FL 32231
028-13	Blue Cross Blue Shield of Georgia, 2357 Warm Springs Rd, PO Box 7368, Columbus, GA 31908

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-3	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
028-18	Blue Cross of California, PO Box 9051, Oxnard, CA 93031-9051
028-19	Blue Cross Blue Shield of Idaho, 3000 E Pine Ave, PO Box 7408, Boise, ID 83707
028-20	Blue Cross Blue Shield of Illinois, 233 N Michigan Ave, PO Box 1364, Chicago, IL 60690
028-22	Blue Cross Blue Shield of Indiana, 5451 Lakeview Pkwy, Indianapolis, IN 46268
028-23	BC Life & Health, PO Box 9201, Oxnard, CA 93031
028-26	Blue Cross Blue Shield of Maryland, PO Box 9784, Baltimore, MD 21284
028-28	Blue Cross Blue Shield of Minnesota, PO Box 64338, St Paul, MN 55164
028-29	Horizon Blue Cross Blue Shield, PO Box 22439, Newark, NJ 22439
028-30	Blue Cross Blue Shield of Kansas City, 2301 Main St, PO Box 419169, Kansas City, MO 64141
028-31	Blue Cross Blue Shield of Pennsylvania, PO Box 898845, Camp Hill, PA 17089
028-32	Carefirst Blue Cross Blue Shield, PO Box 812, Owings Mills, MD 21117-0812
028-33	Horizon BC/BS of New Jersey, PO Box 1609, Newark, NJ 07101
028-34	Blue Cross Blue Shield of North Carolina, 5901 Chapel Hill Rd, PO Box 2291, Durham, NC
27702
028-35	Blue Cross Blue Shield of Oklahoma, PO Box 3283, Tulsa, OK 74102-3283
028-37	Blue Cross Blue Shield of Nebraska, 7261 Mercy Rd, PO Box 3248, Main PO Station, Omaha,
NE 68180
028-38	Blue Cross Blue Shield of New Jersey, 3 Penn Plaza E, Newark, NJ 07105
028-39	Anthem Blue Cross and Blue Shield, 2 Gannett Drive, South Portland, ME 04106-6911
028-41	Anthem Blue Cross Blue Shield, PO Box 37180, Louisville, KY 40233
028-53	Capital Blue Cross, 2500 Elmerton Ave, Harrisburg, PA 17177
028-54	Blue Cross of Western Pennsylvania, 120 Fifth Ave, Pittsburgh, PA 15222
028-55	Blue Cross of Northern Pennsylvania, 70 N Main St, Wilkes-Barre, PA 18711
028-58	Blue Cross of Puerto Rico, PO Box 363628, San Juan, PR 00936
028-59	Blue Cross Blue Shield of Rhode Island, 444 Westminster St, Providence, RI 02903-3279
028-60	Blue Cross Blue Shield of South Carolina, I-20 E at Alpine Rd, Columbia, SC 29219
028-63	Blue Cross Blue Shield of Tennessee, 801 Pine St, Chattanooga, TN 37402
028-66	Blue Cross Blue Shield of Texas, 901 S Central Expressway, PO Box 655730, Dallas, TX 75265
028-68	Trigon Blue Cross Blue Shield, 2015 Staples Mill Rd, PO Box 27401, Richmond, VA 23279
028-71	Blue Cross Blue Shield of Vermont, 445 Industrial Lane, PO Box 186, Montpelier, VT 05601
028-75	Blue Cross Blue Shield United of Wisconsin, PO Box 1582, Milwaukee, WI 53201
028-88	Anthem, PO Box 533, North Haven, CT 06473-0533
028-94	Blue Cross Blue Shield of Texas, PO Box 660044, Dallas, TX 75266-0044
028-95	Trigon Blue Cross Blue Shield, PO Box 27287, Richmond, VA 23261-7287

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-4	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
058-15	Dental Benefit Providers, PO Box 30640, Bethesda, MD 20824-4814
064-01	Champus/Sierra Military Health Systems, PO Box 7011, Camden, SC 29020
064-02	Delta Dental of Rhode Island, Blue Cross Blue Shield, PO Box 1517, Providence, RI 02901
064-03	Delta Dental Plan of Michigan, PO Box 9085, Farmington Hills, MI 48333
064-05	Delta Dental, 401 W Michigan St, Milwaukee, WI 53201
064-06	Delta Dental Plan of Iowa, PO Box 919, Ankeny, IA 50021-0919
064-08	Sierra Military Health Services, Tricare for Life, PO Box 7051, Camden, SC 29020-7051
064-15	Delta Dental of Pennsylvania, 1 Delta Drive, Mechanicsburg, PA 17055
064-16	Delta Dental Plan of Ohio, PO Box 9785, Farmington Hills, MI 48333-9785
064-30	Delta Dental Plan of Arkansas, 100 Shadow Oaks Dr, PO Box 15965, North Little Rock, AR
72231-5965
064-35	Delta Dental Plan of New Jersey, PO Box 222, Parsippany, NJ 07054
064-40	Delta Dental of Missouri, PO Box 8690, St Louis, MO 63126-3126
064-60	Tricare (Pharmacy), PO Box 7011, Camden, SC 79020-0000
083-00	Delta Dental Plan of Massachusetts, PO Box 9695, Boston, MA 02114-9695
084-00	Medicare A Claims
085-00	Medicare B Claims
091-01	Fallon Community Health Plan, Senior, 10 Chestnut St, Worcester, MA 01615
091-05	Fallon Community Health Plan, PO Box 15121, Worcester, MA 01615-0121
092-00	Harvard Pilgrim Health Care, PO Box 699183, Quincy, MA 02269-9183
092-12	Harvard Community Health, First Seniority, PO Box 699183, Quincy, MA 02269-9183
095-00	Mathew Thornton Health Plan, PO Box 9514, Manchester, NH 03108
101-01	Tufts Health Plan, PO Box 9163, Watertown, MA 02471-9163
101-02	Tufts Secure Horizons, PO Box 9106, Waltham, MA 02254-9106
105-00	A-C Retirees Benefits Plan, BPA of Wisconsin, 11270 W Park Place, Suite 950, Milwaukee, WI
53224
106-00	Aetna/US Healthcare, PO Box 3929, Allentown, PA 18106-9861
106-01	Aetna/US Healthcare, PO Box 1858, 1800 E Interstate Ave, Bismark, ND 58502
106-02	Aetna/US Healthcare/Senior, 400-01 Totten Pond Rd, Waltham, MA 02451-2000
106-04	Aetna/US Healthcare, PO Box 981114, El Paso, TX 79998-1114
106-05	Aetna/US Healthcare, 3 Burlington Woods Dr, Burlington, MA 01830
106-06	Aetna/US Healthcare, 3541 Winchester Rd, Allentown, PA 18195
106-07	Aetna/US Healthcare, PO Box 1125, Blue Bell, PA 19422-0770
106-08	Aetna/US Healthcare, PO Box 2295, Fort Wayne, IN 46801

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-5	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
106-09	Aetna/US Healthcare, PO Box 31450, Tampa, FL 33636
106-11	Aetna/US Healthcare, PO Box 24024, Fresno, CA 93779
106-14	Aetna/US Healthcare, PO Box 3909, Allentown, PA 18106-0909
106-18	Aetna/US Healthcare, PO Box 150417, Hartford, CT 06115-0417
106-21	Aetna/US Healthcare, 2675 N Mayfair Rd, PO Box 26599, Milwaukee, WI 53226
106-24	Aetna/US Healthcare, 10401 Linn Station Rd, PO Box 35890, Louisville, KY 40223
106-25	Aetna/US Healthcare, 700 W Highlander Blvd, PO Box 91555, Arlington, TX 76015-0055
106-29	Aetna/US Healthcare, PO Box 4266, Bismarck, ND 58502-4266
106-30	Aetna/US Healthcare, PO Box 44128, Jacksonville, FL 32231-4128
106-31	Aetna/US Healthcare, PO Box 981107, EL PASO, TX 79998-1107
106-34	Aetna/US Healthcare, 10101 Reunion Place, PO Box 28060, San Antonio, TX 78228
106-35	Aetna/US Healthcare, 4050 Piedmont Pkwy, High Point, NC 27607
106-36	Aetna/US Healthcare, 6795 N Palm Ave, 2nd Fl, PO Box 12340, Fresno, CA 93765
106-38	Aetna/US Healthcare, PO Box 18040, Columbus, OH 43218-0040
106-39	Aenta/USHealthcare, PO Box 12905, San Diego, CA 92055
106-45	Aetna/US Healthcare, PO Box 26106, Greensboro, NC 27402-6106
106-47	Aetna/US Healthcare, 3875 Embassy Pkwy, PO Box 5569, Akron, OH 44334
106-52	Aetna /US Healthcare, PO Box 91522, Arlington, TX 76015-0022
106-57	Aetna/US Healthcare, PO Box 16423, Pittsburgh, PA 15242-0723
106-60	Aetna/US Healthcare, PO Box 981109, EL Paso, TX 79998-1109
106-61	Aetna/US Healthcare, PO Box 3925, Allentown, PA 18106
106-62	Aetna/US Healthcare, PO Box 1630, Columbus, OH 43216
106-63	Aetna/US Healthcare, PO Box 14014, Lexington, KY 40512
106-64	Aetna/US Healthcare, PO Box 26103, Greensboro, NC 27402
106-65	Aetna/US Healthcare, P O Box 2520, Tyler, TX 75710-2520
106-67	Aetna/US Healthcare, 1235 N Mulford Rd, PO Box 5048, Rockford, IL 61125
106-68	Aetna/US Healthcare, PO Box 7012, Dover, DE 19901
106-70	Aetna/US Healthcare, PO Box 14110, Lexington, NY 12452-9999
106-71	Aetna/US Healthcare, PO Box 52120, Minneapolis, MN 55402-5120
106-72	Aetna/US Healthcare, Loop Statiom, PO Box 2907, Minneapolis, MN 55402-0907
106-73	Aetna, PO Box 26107, Greensboro, NC 27402-6107
106-74	Aetna/US Healthcare, 4013 NW Expressway S 300, PO Box 12244, Oklahoma City, OK 73116
106-77	Aetna/US Healthcare, PO Box 52121, Minneapolis, MN 54402

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-6	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
106-79	Aetna US Healthcare, PO Box 14586, Lexington, KY 40512-4586
106-80	Aetna/US Healthcare, PO Box 1214, Tewksbury, MA 01876
106-81	Aetna/US Healthcare, PO Box 129104, San Diego, CA 92112-0000
106-83	Aetna/US Healthcare, PO Box 14089, Lexington, KY 40512-4089
106-87	Aetna/Us Healthcare, PO Box 2950, Loop Station, Minneapolis, MN 55402-000
106-92	Aetna/US Healthcare, PO Box 14094, Lexington, KY 40512-4094
106-94	Aetna/US Healthcare, PO Box 182082, Columbus, OH 43218
106-96	Aetna Healthcare, PO Box 981107, EL Paso, TX 79998-1107
106-97	Aetna/US Healthcare, PO Box 129010, San Diego, CA 92112
106-99	Aetna/US Healthcare, 3 Centerview Dr, PO Box 26190, Greensboro, NC 27402
127-04	Corporate Diversified Services, PO Box 2835, Omaha, NE 68103-2835
128-00	American Heritage Life Insurance, 1776 American Heritage Life Dr, Jacksonville, FL 32224
135-08	American Medical Security, PO Box 19032, Green Bay, WI 54307
138-01	American National Insurance, Regional Group Services Office, Suite 300, North Andover, MA
01845
138-10	Amerihealth Administrators, 720 Blair Mill Road, Horsham, PA 19044-2269
143-04	American Veterinary Medical Assoc, 55 E Jackson Blvd, 8th Fl, Chicago, IL 60604
144-40	Ameritas Life Insurance, PO Box 82520, Lincoln, NE 68501
149-16	Associated Plan Admin, PO Box 189, Columbus, OH 43216
149-18	Associated Plan Admin, PO Box 9568, New Haven, CT 06535
154-10	Bankers Life & Casualty, 222 Merchandise Mart Plaza, 5th, PO Box 66927, Chicago, IL 60654
167-00	Boston Mutual Life Insurance, 120 Royall St, Canton, MA 02021
171-00	Washington National, PO Box 1250, Rockford, IL 61105
171-01	Washington National, Health Claims Dept, 399 Market St, Philadelphia, PA 19181-1250
178-00	Century Indemnity, 55 Elm St, Hartford, CT 06115
182-00	Chesapeake Life Insurance, PO Box 982017, North Richland Hill, TX 76182
183-50	Chickering Claim Administrators Inc, PO Box 410378, Cambridge, MA 02141
184-10	Christian Brothers Health Management Services, 1205 Windham Parkway, Romeoville, IL
60446-1672
187-00	Collegiate Risk Management, PO Box 727, Short Hills, NJ 07078-0727
194-01	Combined Insurance of America, 111 Washington St, Brookline, MA 02445
194-02	Combined Insurance Company, PO Box 638, Bellingham, WA 98227-0638
200-00	Cigna, PO Box 8012, Plainville, CT 06062
200-02	Cigna Healthare, PO Box 5067, Visalia, CA 93279

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-7	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
200-03	Cigna, PO Box 2083, Concord, NH 03302
200-06	Cigna Health Plan, PO Box 188002, Chattanooga, TN 37422-8002
200-08	Cigna Healthcare, PO Box 5200, Scranton, PA 18505-5200
200-09	Cigna, 1055 Franklin Ave, Garden City, NJ 11530
200-10	Cigna, PO Box 5019, Visalia, CA 93278
200-11	Cigna, PO Box 3077, Bourbonnais, IL 60914
200-12	Connecticare, PO Box 546, Farmington, CT 06034-0546
200-14	Cigna, PO Box 2546, Sherman, TX 75091
200-16	Cigna Healthcare, PO Box 10485, Des Moines, IA 50306-0485
200-19	Cigna, PO Box 49400, Atlanta, GA 30359
200-20	Cigna Healthcare, Station B, PO Box 6185, Greenville, SC 29605-6185
200-21	Cigna, PO Box 24009, Fresno, CA 93779
200-22	Cigna Healthcare, PO Box 34335, Charlotte, NC 28244
200-23	Cigna, PO Box 1970, Bourbonnais, IL 60914
200-26	Cigna, PO Box 8013, Plainville, CT 06062
200-29	Cigna Healthcare, PO Box 182532, Columbus, OH 43218
200-33	Cigna, PO Box 5046, Southfield, MI 48086
200-36	Cigna Healthcare, PO Box 15538, Wilmington, DE 19850-5538
200-38	Cigna, PO Box 182014, Columbus, OH 43218
200-39	Cigna Healthcare, PO Box 3087, Bourbonnais, IL 60914
200-40	Cigna Healthcare, PO Box 5353, Melville, NY 11747-5353
200-41	Cigna, PO Box 3040, Bourbonnais, IL 60914
200-42	Cigna, PO Box 2100, Bourbonnais, IL 60914
200-43	Cigna, PO Box 964, Bristol, CT 06011-0964
200-44	Cigna Healthcare, PO Box 182717, Columbus, OH 43218-2717
200-45	Cigna Healthcare, PO Box 182654, Columbus, OH 43218-2654
200-46	Cigna Healthcare, PO Box 2041, Concord, NH 44077-7041
200-48	Cigna Healthcare, PO Box 354, Avon, CT 06001-0354
200-49	Cigna, PO Box 2005, Farmington, CT 06034
200-50	Cigna Dental, PO Box 15558, Wilmington, DE 19850
200-51	Cigna Healthcare, PO Box 5008, Visalia, CA 92378
200-52	Cigna Healthcare, PO Box 188008, Chattanooga, TN 37442-0000
200-54	Cigna Healthcare, PO Box 1269, Farmington, CT 06034-1269

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-8	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
200-55	Cigna Healthcare, PO Box 188024, Chattanooga, TN 37422
200-56	Cigna Healthcare, PO Box 188029, Chattanooga, TN 37422-8029
200-57	Cigna Healthcare, PO Box 80000, Atlanta, GA 30359
200-58	Cigna Healthcare, PO Box 188006, Chattanooga, TN 37422-8006
200-61	Cigna PPA, PO Box 188007, Chattanooga, TN 37422-8007
200-62	Cigna Health Plan of Massachusetts, PO Box 5023, Hartford, CT 06102
200-64	Cigna Behavioral Health, PO Box 46270, Eden Prairie, MN 55344
200-66	Cigna Healthcare, PO Box 3070, Bourbonnais, IL 60914-3070
200-67	Cigna, PO Box 188004, Chattanooga, TN 37422-8004
200-68	Cigna, PO Box 188031, Chattanooga, TN 37422
200-70	Cigna, PO Box 800, Unionville, CT 06085
200-72	Cigna, PO Box 188031, Chattanooga, TN 37422
200-74	Cigna, PO Box 33668, Charlotte, NC 28233
200-75	Cigna Dental, PO Box 188003, Chattanooga, TN 37422-8003
200-76	Cigna, PO Box 34336, Charlotte, NC 28234
200-77	Cigna Health Plan of Massachusetts, PO Box 902, Unionville, CT 06085
200-78	Cigna, PO Box 3219, Cincinnati, OH 45202
200-80	Cigna, PO Box 352, Avon, CT 06001-0354
200-81	Cigna, PO Box 9155, Des Moines, IA 50306
200-82	Cigna Dental Health, PO Box 4630, Miami, FL 33269
200-83	Cigna Dental, PO Box 969, Bristol, CT 06010
200-86	Cigna, PO Box 29000, Atlanta, GA 30359-9000
200-87	Cigna Dental, PO Box 189060, Plantation, FL 33318
200-89	Cigna Healthcare, PO Box 182223, Chattanooga, TN 37422-0000
200-90	Cigna Healthcare, PO Box 36125, Charlotte, NC 28230
200-92	Cigna, PO Box 15050, Wilmington, DE 19850
200-93	Cigna, PO Box 9317, Des Moines, IA 50306
200-94	Cigna Healthcare, PO Box 188026, Chattanooga, TN 37422-8026
200-95	Cigna Healthcare, PO Box 188009, Chattanooga, TN 37422-000
200-96	Cigna Preferred, PO Box 71203, San Juan, PR 00936-8703
200-97	Cigna, PO Box 49410, Atlanta, GA 30359-1410
200-98	Cigna Healthcare, PO Box 188030, Chattanooga, TN 37422
203-00	Consolidated Health Plans, 195 Stafford St, Springfield, MA 01124-3500

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-9	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
203-01	Constitution Health Network, PO Box 720, North Haven, CT 06473
214-01	Cypress Benefit Administrators, PO Box 7020, Appleton, WI 54912
214-02	Cuna Mutual Insurance Society, Claim Services, Valley Forge, PA 19495
226-31	The Equitable, PO Box 3000, Lancaster, SC 29721-3000
226-33	Equitable Life & Casualty, PO Box 2460, Salt Lake City, UT 84110
226-35	Equitable General Insurance, Geico Plaza, Washington, DC 20076
230-00	Farm Family Life Insurance, PO Box 656, Albany, NY 12201
242-00	Fidelity Security Life Insurance, 3130 Broadway, PO Box 418131, Kansas City, MO 64141
247-05	Pro-Net, PO Box 101387, Fort Worth, TX 76185-1387
248-20	Fleet Reserve Assoc Insurance (FRA), 400 Locust St, 8th Fl, Des Moines, IA 50398
253-60	Fortis Benefits Insurance, 2323 Grand Blvd, Kansas City, MO 64108-2654
255-01	Tri Span Medicare Part A, PO Box 23046, Jackson, MS 39225-3046
260-00	Gerber Life Insurance, 204 West Main St, Freemont, MI 49412
262-00	Global Exchange, PO Box 823067, South Florida, FL 33082-3067
265-00	Golden Rule Insurance, 712 Eleventh St, Lawrenceville, IL 62439
265-01	Golden Rule Insurance, 7440 Woodland Dr, Golden Rule Building, Indianapolis, IN 46278
266-01	Government Employees Hospital Assoc, PO Box 4665, Independence, MO 64051
275-12	Great West/Private Healthcare Systems, PO Box 5180, Des Plains, IL 60017
275-15	Great West Accounts, 1000 Great West Drive, Kennett, MO 63857-3749
275-18	Great West Life/One Health Plan, PO Box 11111, Fort Scott, KS 66701
280-00	Guardian Short Term Disability, PO Box 26160, Lehigh Valley, PA 18002-6160
280-06	The Guardian, PO Box 9128, Norwell, MA 02061
280-08	Guardian, PO Box 8019, Appleton, WI 54913
280-11	Guardian Life Insurance, PO Box 26020, Lehigh Valley, PA 18017-6020
280-27	Guardian Life, PO Box 9129, Norwell, MA 02061
280-32	Guardian Life, PO Box 2467, Spokane, WA 99210-2469
280-33	Guardian Dental, PO Box 2459, Spokane, WA 99210-2459
280-35	Guardian, PO Box 424 Suite 2, East Bridgewater, MA 02333-0424
288-20	Healthnet, PO Box 7090, Bridgeport, CT 06601-0981
288-21	ACS Health Net Of North East, PO Box 14700, Lexington, KY 40512-4700
288-25	Healthnet PPO, PO Box 10223, Van Nuys, CA 91410-0223
288-30	Health Partners, PO Box 5194, New York, NY 10185-5191
288-54	Health Plans, PO Box 290800, Boston, MA 02129

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-10	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
288-76	Health Scope Benefits, PO Box 3726, Little Rock, AR 72203-3726
290-50	Boon-Chapman, PO Box 9201, Austin, TX 78766
292-03	Anthem/Home Life Insurance, PO Box 1326, Piscataway, NJ 08855-1326
300-20	Independent Health, PO Box 1430, Buffalo, NY 14231
304-00	Inter Americas Insurance Corporation, PO Box 9510, Wichita, KS 67277-0510
305-02	Intercounty Hospital Plan, 720 Blair Mill Road, Horsham, PA 19044-2269
307-03	International Medical Group, 407 N Fulton St, Indinanpolis, IN 46202-3684
313-00	John Alden Life Insurance, PO Box 1508, Minneapolis, MN 55480
313-03	John Alden, PO Box 020270, Miami, FL 33102
313-04	John Alden Insurance, PO Box 1108, Metro Place N, #200, Dublin, OH 43017
313-07	John Alden, PO Box 9398, Minneapolis, MN 55440
313-10	John Alden, PO Box 527750 S-190, 5835 Blue Lagoon Dr, Miami, FL 33152
314-00	John Deere Insurance, PO Box 620, 34th Ave & 80th St, Moline, IL 61265
315-00	John Hancock Mutual Life Insurance, PO Box 111, Boston, MA 02117
315-01	John Hancock Mutual Life Insurance, PO Box 4000, Braintree, MA 02184
315-04	John Hancock Insurance, PO Box 4061, Schaumburg, IL 60168
315-12	John Hancock Mutual Life Insurance, Exxon Claim Office, PO Box 8515, London, KY
47042-8515
315-13	John Hancock Mutual Life Insurance, Group Claims, PO Box 4005, Shaumburg, IL 60168
315-16	Unicare, PO Box 5005, Bollingbrook, IL 60440
315-21	John Hancock Preferred Health Plan, Group Claims Office, PO Box 9115, Braintree, MA 02184
315-23	Unicare, Association National Claim, 13523 Barrett Pkwy Dr, Baldwin, MO 63011
315-25	John Hancock Insurance, PO Box 833898, Richardson, TX 75083-3898
315-29	Unicare, Client Service Center, PO Box 4050, Schaumburg, IL 60168
315-31	Unicare, PO Box 7062, Schaumburg, IL 60168-4062
315-32	Unicare, PO Box 4069, Schaumburg, IL 60168-4069
315-35	Unicare, GIC Indemnity Plan, PO Box 9016, Andover, MA 01810
315-38	John Hancock, PO Box 2074, Aurora, IL 60507
315-42	John Hancock, PO Box 9186, Braintree, MA 02184
315-46	Unicare, Greensboro Client Services, 7025 Albert Pick Rd, # 500, Greensboro, NC 27420-6089
315-51	Unicare, PO Box 51130, Springfield, MA 01151
315-52	Unicare, PO Box 51990, Indian Orchard, MA 01151
315-53	Unicare/John Hancock Mutual Life, PO Box 1993, Andover, MA 01810

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-11	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
315-55	Unicare Dental, PO Box 9201, Oxnard, CA 91331-9201
315-57	Unicare, PO Box 51130, Springfield, MA 01151-5130
315-58	John Hancock, PO Box 4034, Shaumburg, IL 60168
315-72	John Hancock Financial Services, PO Box 3010, Andover, MA 01810
315-78	Unicare, PO Box 833933, Richardson, TX 75083-3933
315-79	Unicare Compaq Claims, PO Box 833895, Richardson, TX 75083-895
315-80	Unicare, PO Box 26710, Greensboro, NC 27417-6710
315-90	Unicare, PO Box 51180, Indian Orchard, MA 01551-5180
315-91	Unicare Teacher's Choice Health Plan, PO Box 5027, Bollingbrook, IL 60440-5027
315-92	Unicare, PO Box 061109, Chicago, IL 60606-1109
315-95	Unicare, PO Box 4062, Schaumburg, IL 60168-4062
322-04	Awane Benefit Plan Management, PO Box 536, Rockland, MA 02370-0536
322-11	Liberty Mutual, PO Box 9004, Central Islip, NY 11722-9004
331-00	Lincoln National Life Insurance, 1300 S Clinton St, Fort Wayne, IN 46801
334-01	Loomis Company, PO Box 7011, Wyomaissing, PA 19610-6011
348-03	Mass Mutual Life Insurance, PO Box 60004, City of Industry, CA 91716
348-14	Mass Mutual, 35 Circle Park, Austin, TX 78753
348-18	Mass Mutual Life Insurance, PO Box 9048, Springfield, MA 01151
348-20	Mass Mutual, 1320 Willard Rd Suite, One Corporate Center, Concord, CA 94520
348-25	Mass Mutual, PO Box 90190, Highland Station, Springfield, MA 01139
348-40	Mid-Atlantic Medical Services/MAMSI, PO Box 930, Frederick, MD 21705-0930
349-80	Medspan, Inc, PO Box 340950, Hartford, CT 06134-0950
351-00	Metropolitan Life Insurance, Claims, 1 Madison Ave, New York, NY 10010
351-01	United Healthcare/Metrahealth, PO Box 30555, Salt Lake City, UT 84130-0555
351-02	Metropolitan Life Insurance, PO Box 30430, Metropolitan Plaza, Tampa, FL 33630
351-03	Met Life Dental, PO Box 14093, Lexington, KY 40512-4093
351-05	United Healthcare, PO Box 1600, Kingston, NY 12402
351-07	Metropolitan Life Insurance, Group Health Claims, 700 Quaker Lane, PO Box 300, Warwick, RI
02887
351-12	Metropolitan Life Insurance, Group Claims Office, 9797 Springboro Pike, Dayton, OH 45448
351-16	United Healthcare, PO Box 740801, Atlanta, GA 30374
351-17	United Healthcare, GTE Claim Service Center, PO Box 740803, Atlanta, GA 30374
351-18	United Healthcare, PO Box 740800, Atlanta, GA 30374-0800

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-12	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
351-20	United Healthcare, PO Box 310, Pueblo, CO 81002
351-24	United Healthcare, PO Box 740802, Atlanta, GA 30374-0802
351-27	Metropolitan Life, 99 High St, 21st Fl, Boston, MA 02111
351-29	Metro Insurance, PO Box 495, Warwick, RI 02887
351-32	Metropolitan Insurance, PO Box 7777, Utica, NY 13504
351-35	United Healthcare, 1952 Whitney Ave, Group Health Claims, Hamden, CT 06517-1209
351-36	Metro, PO Box 30195, Tampa, FL 33630
351-38	United Healthcare, PO Box 2517, Smyrna, GA 30081-2517
351-41	Metro, PO Box 470, Warwick, RI 02887
351-45	Metropolitan Life Insurance, PO Box 969, 4 British American Blvd, Latham, NY 12110
351-47	Metro Dental Claims, PO Box 460, Warwick, RI 02887
351-50	Metropolitan-Group Dental Claims, PO Box 5200, Greenville, SC 29606
351-53	Metropolitan Life Insurance Group Claims, PO Box 469, Warwick, RI 02886
351-55	United Healthcare/Evercare, PO Box 169065, Rt 2913, Duluth, MN 55816-8351
351-57	United Healthcare Insurance, PO Box 5090, Rolling Meadows, IL 60008
351-60	Metropolitan Health Insurance, PO Box 2950, Englewood, CO 80110
351-61	Metropolitan Health Insurance, 960 Main St, Hartford, CT 01115
351-64	United Health Care, PO Box 30551, Salt Lake City, UT 84130
351-74	United Healthcare/Metropolitan, GE Medical Benefits, PO Box 3025, Utica, NY 13504
351-75	Metropolitan Life, PO Box 1922, Indianapolis, IN 46206
351-79	United Health Care, PO Box 659768, San Antonio, TX 78265-9768
351-83	Metropolitan, PO Box 450, Warwick, RI 02887
351-84	United Healthcare, PO Box 659744, San Antonio, TX 78265-9744
351-85	United Healthcare, PO Box 6022, Schenectady, NY 12301-9013
351-86	Metropolitan, PO Box 6017, Newark, DE 19714
351-88	Metropolitan Life Dental Claims, PO Box 2579, Pittsburgh, PA 15230
351-99	Metropolitan Life, Dental Benefits Claims C, PO Box 8740, Dayton, OH 45401
352-11	United Concordia, UCCI PO Box 69421, Harrisburg, PA 17106-9421
352-12	United Concordia, PO Box 69421, Harrisburg, PA 17106-9421
357-10	Midwest National Life Insurance, PO Box 982017, North Richland Hills, TX 76182-8017
362-04	Monumentary General Insurance, 1111 N Charles, Baltimore, MD 21201
362-10	Monumental Insurance, PO Box 97, Scranton, PA 18504
366-01	Mutual of Omaha, Mutual of Omaha Plaza, Omaha, NE 68175

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-13	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
366-04	Mutual of Omaha, 6301 Ivy Lane, #100, Greenbelt, MD 20770
366-05	Mutual of Omaha, 1160 Bay St, Springfield, MA 01109
366-06	Mutual of Omaha, Woodward Healthcare Center, PO Box 9, Woodward, OK 73802-0009
366-11	Mutual of Omaha, PO Box 668329, Charlotte, NC 28266
371-00	National Elevator Industries, PO Box 477, Newtown Sq, PA 19073
374-00	National Financial Insurance, 110 W 7th St, Fort Worth, TX 76102
376-03	National Health Insurance, PO Box 619999, Dallas/Ft Worth Airport, TX 75261-6199
378-00	Peoples Benefit Life Insurance Company, Claims Dept., Valley Forge, PA 19493-0001
379-10	National Health Insurance Co., P O Box 619999, Dallas, TX 75261-6199
388-00	New England Financial, 900 Second Ave, Suite 650, Minneapolis, MN 55402-3341
388-01	New England Financial, PO Box 8020, North Olmsted, OH 44070
388-06	New England Financial/One Health, PO Box 11111, Fort Scott, KS 66701
388-12	New England Financial, PO Box 7000, Coraopolis, PA 15108
388-35	New England Financial/One Health, PO Box 30466, Tampa, FL 33630
390-00	New York Life Insurance, 3316 Farnam St, Omaha, NE 68175
390-01	New York Life Insurance, Claims, PO Box 64022, Phoenix, AZ 85082
390-09	New York Life, PO Box 92449, Chicago, IL 60675
390-12	New York Life Insurance, PO Box 4000, Group Claims Office, Freehold, NJ 07728
394-01	Trans America Insurance Company, PO Box 982009, North Richland Hills, TX 76182-8009
397-01	North America Life & Casualty, Medical Claims Services, 119 Beach St, Boston, MA 02111
397-30	North American Preferred, PO Box 9501, Amherest, NY 14226-9501
398-40	State of North Carolina Teacher & State Employees, PO Box 30025, Medical Plan, Durham, NC
27702-3025
405-02	Northwest National Life, PO Box 5222, Norwalk, CT 06856
406-00	Coresource, 20 Washington Ave S, Minneapolis, MN 55440
406-01	Northwestern National, 180 Greenleaf Ave, Portsmouth, NH 03801
406-06	Northwestern National Life, PO Box 2264, Hill Haven Corporation, Tacoma, WA 98401
406-24	Coresource, 7830 E Broadway, Tucson, AZ 85710-3923
414-01	Oxford Life Insurance Company, PO Box 46518, Madison, WI 53744-6518
414-02	Oxford Health Plan, PO Box 7082, Bridgeport, CT 06601-7081
416-01	Pacific Fidelity Insurance, PO Box 1038, Hurst, TX 76053
418-06	Pacific Life & Annuity Company, PO Box 34799, Phoenix, AZ 85067-4799
421-00	Primary Physician Care, 1515 Mockingbird Lane, Charlotte, NC 28220-1088

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-14	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
425-20	Pennsylvania Employee Benefit Trust, 150 South 43rd St, Suite 1, Harrisburg, PA 11711-5708
430-00	Phoenix Insurance, One Tower Sq, Hartford, CT 06115
430-02	Phoenix Group Services, 701 Highlander, 400 PO Box 150809, Arlington, TX 76015
430-03	Phoenix Life, One American Row, Hartford, CT 06115
430-04	Phoenix Mutual Life, PO Box 677, Greenfield, MA 01302
430-10	Phoenix, PO Box 1477, Greenfield, MA 01302
430-12	The Phoenix, Employee Agent Claims Unit, PO Box 810, Greenfield, MA 01302
431-40	Physicians Care Plus, PO Box 31286, Tampa, FL 33631
432-00	Physicians Mutual Insurance, PO Box 2018, Omaha, NE 68103-2018
432-30	Pine Health Benefits, PO Box 2160, Natick, MA 01760
433-01	Pioneer Management Systems, PO Box 6600, Holyoke, MA 01040
433-02	Pioneer Life Insurance, PO Box 5151, Janesville, WI 53547-5151
435-00	Pinkerton, Ultralink (TPA), PO Box 5049, Costa Mesa, CA 92628
435-05	PPONEXT, PO Box 2000-214, Mission Viejo, CA 92692
439-00	Cigna, PO Box 182523, Chattanooga, TN 37422
439-01	Provident Life Insurance, 31 Milk St, Boston, MA 02101
439-03	Provident Life & Accident Insurance, 1241 Volunteer Pkwy, Suite 1000, Bristol, TN 37620
439-04	Connecticare, PO Box 522, Farmington, CT 06032
439-06	Health Source, PO Box 180149, Chattanooga, TN 37422
439-07	Connecticare, 30 Batterson Park Rd, Farmington, CT 06032
439-09	Cigna, PO Box 64143, St Paul, MN 55164
439-10	Provident Mutual Life, PO Box 7378, Philadelphia, PA 19101
439-12	Cigna Healthcare, PO Box 2048, Gastonia, NC 28053
439-13	Cigna Healthcare, PO Box 219700, Houston, TX 77218
439-31	Health Source, PO Box 190023, N Charleston, SC 21419
439-53	Cigna Healthcare, PO Box 5200, Scranton, PA 18505-5200
439-55	Cigna, PO Box 31066, Charlotte, NC 28321-1066
439-56	Cigna Healthcare, PO Box 8014, Plainville, CT 06062
441-00	Prudential Insurance, PO Box 2000, Millville, NJ 08332
441-01	Prudential, 50 Federal St, Boston, MA 02101
441-03	Prudential, Small Group Health Claim D, PO Box 2229, Jacksonville, FL 32231
441-05	Prudential Insurance, PO Box 930, Horsham, PA 19044
441-08	Prudential Insurance, PO Box 690, Akron, OH 44309

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-15	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
441-09	Pru-Care Plus, PO Box 45197, Jacksonville, FL 32233
441-14	Prudential Insurance, PO Box 4000, Millville, NJ 08332
441-15	Prudential Insurance, PO Box 2018, Millville, NJ 08332
441-18	Prudential Insurance, PO Box 5100, Rockaway, NJ 07866
441-31	Prudential, 433 W Main St, Box 400, Hyannis, MA 02601
441-35	Prudential, PO Box 1400, One Campus Dr, Parsippany, NJ 07054
441-36	Prudential, PO Box 44039, Jacksonville, FL 32231
441-37	Prudential Group Health Claims North, PO Box 4804, Houston, TX 77210-4804
441-48	Prudential, PO Box 15045, Albany, NY 12212
441-50	Prudential Insurance of America, PO Box 10100, High Point, NC 27261
441-55	Prudential, 30 Capital Dr, West Springfield, MA 01089
441-60	Prudential, PO Box 8000, Millville, NJ 08332
441-61	Prudential, PO Box 2020, Millville, NJ 08332
441-74	Prucare, PO Box 15075, Albany, NY 12212
442-50	PEHP (Public Employees Healthplan), 560 East 200 South, Salt Lake City, UT 84102
444-10	RMSCO, PO Box 6309, Syracuse, NY 13217-6309
451-10	Reserve National Insurance, PO Box 26620, Oklahoma City, OK 73126-0620
480-00	Time Insurance, PO Box 624, 515 W Michigan Ave, Milwaukee, WI 53201
488-00	United Healthcare Insurance, PO Box 9516, New Haven, CT 06534-0516
488-02	United Healthcare, PO Box 740122, Atlanta, GA 30374
488-03	United Healthcare Insurance, PO Box 473519, Charlotte, NC 28247-3519
488-17	Metrahealth/United Healthcare, 1701 Pine Croft Rd, PO Box 26722, Greensboro, NC 27417
488-25	Travelers Insurance, PO Box 4215, Atlanta, GA 30302
488-30	United Healthcare of New England, 475 Kilvert St, PO Box 1070, Warwick, RI 02886-1392
488-35	United Health/Railroad/Active Employees, PO Box 30985, Salt Lake City, UT 84130-0122
488-53	United Healthcare/Railroad/Medicare/Over 65, PO Box 30304, Salt Lake City, UT 84130-0122
488-62	United Healthcare, PO Box 26722, Greensboro, NC 27417
489-00	Trustmark Insurance, PO Box 9137, Fort Worth, TX 76147-2137
489-10	Trustmark Insurance, PO Box 7900, Lake Forest, IL 60045-7900
489-45	UCC Claims, PO Box 197629, Louisville, KY 40259-7629
491-00	Union Fidelity Life Insurance, 4850 Street Rd, Trevose, PA 19049
493-00	Union Labor Life Insurance, 360 Park Ave S, 2nd Fl, New York, NY 10010
493-02	Union Labor Life Insurance, 161 Forbes Rd, Suite 204, Braintree, MA 02184

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-16	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
498-00	United American Insurance Company, PO Box 8080, Mckinney, TX 75070
498-40	United Church of Christ, PO Box 197629, Louisville, KY 40259-7629
501-00	United Commercial Travelers of America, 632 N Park St, Columbus, OH 43215-8619
508-01	United States Life Insurance, PO Box 1581, MSN 2 E, Neptune, NJ 07754-1581
508-40	United Medical Resources, PO Box 145804, Cincinnati, OH 45221
508-43	United Medical Resources, PO Box 141337, Cincinnati, OH 45250
510-01	Universal Health Service, PO Box 2843, Warminster, PA 18974-2843
512-20	Upstate Administrative Service, PO Box 6589, Syracuse, NY 13217-6589
513-01	Utica Mutual Insurance, 401 Edgewater Place, Suite 300, Wakefield, MA 01880
516-50	Walmart Benefit Adminstration, 922 West Walnut, Suite A, Rogers, AR 72756
524-02	World Insurance, PO Box 3160, Omaha, NE 68103
528-00	Amalgamated Health, PO Box 1449, New York, NY 10116
528-01	Amalgamated Insurance, 867 State Rd, North Dartmouth, MA 02724
528-06	Amalgamated Life Insurance, 333 S Ashland Ave, Chicago, IL 60607
528-10	Amalgamated Insurance, 99 University Place, New York, NY 10003
528-13	Amalgamated Life Insurance, PO Box 1440, New York, NY 10116
562-00	Hartford Insurance, PO Box 1000, Shelton, CT 06484
562-02	Hartford Life Senior Medical Claims, PO Box 5036, Hartford, CT 06102-5036
562-04	Hartford Insurance, PO Box 11910, Alexandria, VA 22312
564-00	Harvard University, 1350 Massachusetts Ave, Cambridge, MA 02138
580-10	Polaris Benefit Administrator, PO Box 2090 C, Stow, OH 44224-0090
589-00	Sentry Life Policy Benefits, PO Box 8025, Stevens Point, WI 80255
600-00	Veterans Aid and Attendance, JFK Building, Government Center, Boston, MA 02203
600-10	Allied Benefit Systems, PO Box 909786-60690, Chicago, IL 60696-0001
600-60	Vicare Care, PO Box 530, Suffolk, VA 23439
600-90	Group Health Insurance, PO Box 2832, New York, NY 10116
602-01	Wausau Benefits (Georgia Pacific Group), PO Box 8092, Wausau, WI 54402-8092
602-02	Wausau Insurance, 115 W Wausau Ave, PO Box 8013, Wausau, WI 54402-8013
606-00	MMSI, 4001 41st Street NW, Rochester, MN 55901-8901
606-02	MVP, 111 Liberty Street, PO Box 2207, Schenectady, NY 12301-2207
606-04	MVP Select Care Inc, PO Box 1434, Schenectady, NY 12301
609-00	Mail Handlers Benefit Plan, PO Box 45118, Jackson, FL 32232-5118
609-02	Mail Handlers Benefit Plan, PO Box 44242, Jacksonville, FL 32231-4242

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-17	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
609-03	National Association of Letter Carriers Health Plan, 20547 Waverly Ct, Ashburn, VA 22093
609-04	Postmasters Benefit Plan, PO Box 1040, Columbia, MD 21044
610-10	NPPN, PO Box 7047, Middletown, NY 10940
610-50	Benefit Plan Management, PO Box 536, Rockland, MA 02370
611-02	National Association (Self-Employed), 41 N Summer St, Holyoke, MA 01042
614-00	Teamsters Health Services, 400 Chapel Rd, Local 559, South Windsor, CT 06074
614-01	IUNH Health and Welfare, 1101 N Lake Destiny Rd, Suite 130, Maitland, FL 32751
614-02	Teamsters Union 25 Health Services, 16 Sever St, Sullivan Sq, Charlestown, MA 02129
614-04	Mass Laborers Benefit Fund, PO Box 4000, Burlington, MA 01803
614-06	Health and Welfare Fund, The London Agency Ltd, 40 Commercial Way, East Providence, RI
02914-004
614-07	Ironworkers Union Local 7, 100 Charles River Plaza, Brighton, MA 02135
614-08	Bakery & Confectionary Union, 10401 Connecticut Ave, Kensington, MD 20895
614-09	IBEW Workers, PO Box 1238, Lakeville, MA 02347
614-10	Northern New England Carpenters Health & Welfare, 250 Center St, PMB 361, Auburn, ME
04210
614-11	Mass State Carpenters Health and Welfare, PO Box 7075, Wilmington, MA 01887
614-15	Plumber's Union Health and Welfare Local 12, 1240 Mass Ave, Boston, MA 02125
614-16	UFCW Local 1459, 33 Eastland Street, Springfield, MA 01109
614-17	Teamsters Health and Welfare, 650 Beacon St, Boston, MA 02115
614-18	IBEW Local 103, 256 Freeport St, Boston, MA 02122
614-20	Bricklayers and Mason Local 3, 645 Morrissey Blvd, Dorchester, MA 02122
614-21	Mason Health and Welfare Local 534, 7 Frederika St, Dorchester, MA 02145
614-22	Local 4, 3001 University Ave SE, Suite 506B, Minneapolis, MN 55414
614-24	New England Teamsters, PO BOX 38, North Andover, MA 01845-0038
614-25	Empire Health Choice Local 99 ILGWU, PO Box 1407, Church St Station, New York, NY 10008
614-27	United Food and Commercial Workers, 290 Post Rd W, PO Box 470, Westport, CT 06881
614-29	Boilermakers National Health and Welfare, 754 Minnesota Ave, Suite 522, Kansas City, KS
66101
614-30	Teamsters Health and Welfare Local #170, 805 Millbury St, Worcester, MA 01607
614-40	Electrical Workers Health & Welfare Fund, 256 Freeport St, Local 103, Boston, MA 02122
614-41	IUOE Local #4 Health & Welfare, 177 Bedford St, PO Box 4, Lexington, MA 02420
614-43	New England Laundry Worker Insurance, 697 Broadway, Somerville, MA 02144
614-46	American Postal Workers Union, PO Box 967, Silver Springs, MD 20910

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-18	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
614-49	United Furniture Workers, PO Box 100037, Nashville, TN 37224
614-52	Teamsters Local 59, 62 South Sixth Street, New Bedford, MA 02740-5907
614-54	Carpenters Health & Welfare, 29 Oakland St, Springfield, MA 01101
614-62	Teamesters Health Services Local 404, PO Box 1370, Springield, MA 01101-1370
614-66	Operating Engineers Health and Welfare Local 98, PO Box 217, East Longmeadow, MA 01028
614-68	SEIU Local 254, 11 Beacon Street, Suite 200, Boston, MA 02108-3002
614-70	Teamsters Local 671 Hlth Svs, 112 Spencer St, Manchester, CT 06040
614-88	Teamsters Central States, PO Box 5103, Des Plaines, IL 60017
614-89	Amalgamated Clothing Textile, Claims Dept, 730 Broadway, New York, NY 10003
614-90	Health & Welfare Fund, 140 Wood Rd, Suite 104, Braintree, MA 02184
615-00	University of Mass Supplemental Health Insurance, University Center, Amherst, MA 01003
615-11	UFCW National Health & Welfare, PO Box 751, Englewood, NJ 07631
615-12	Painters District Council Local 35, 25 Colgate Rd, Roslindale, MA 02131
615-24	New England Electrical Worker's Benefits, PO Box 5817, Wallingford, CT 06492-7617
615-26	New England Health Care Welfare Fund, 77 High Shop Ave, Hartford, CT 06106
615-41	IBEW Local 322, 2000 Springer Dr, Lumbard, IL 60148
615-44	UFCW District 5, 108-36 Queens Blvd, Forest Hills, NY 11375
615-49	Teamsters Union Local 20, 435 South Halley Street, Toledo, OH 43609-2398
615-52	Sheet Metal Workers Natl Hlth Fund, PO Box 1449, Goodlettville, TN 37070-1449
616-00	AARP, PO Box 740819, Atlanta, GA 30301-3074
616-01	AARP, 215 Long Beach Blvd, Long Beach, CA 90801
619-00	Hospital Benefits Inc, PO Box 162148, Altamonte Springs, FL 32716
621-03	National Foundation Life Insurance Co, 777 Main Street, Forth Worth, TX 62103
622-00	Medical Claims Service, One Wall St, Suite 2A, Ravenswood, WV 26164
622-15	Medical Claims Service, 100 River Ridge Dr, Norwood, MA 02062
623-00	HCH Admin, PO Box 1986, Peoria, IL 61656-1986
624-00	American Chambers Life Insurance, PO Box 3048, 1805 High Point Dr, Naperville, IL 60566
625-00	TR Paul, PO Box 5508, Commerce Rd, Newtown, CT 06470
626-00	St Paul Electrical Construction, Medical Reimbursement Plan, 1330 Conway St, St Paul, MN
55106
628-00	One Health Plan, PO Box 11111, Fort Scott, KS 66701-7111
630-10	J F Molloy & Associates, PO Box 68947, Indianapolis, IN 46268
630-70	EPOCH, 10795 Watson Rd, St Louis, MO 63127

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
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	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
638-00	James Galbraith and Green, 757 E South Temple, Salt Lake City, UT 84102
638-02	First Health, PO Box 11038, Scottsdale, AZ 85271
638-03	First Health, PO Box 27142, Baltimore, MD 21230
638-04	First Health, PO Box 23159, Tucson, AZ 85734
638-17	First Health, PO Box 22410, Tucson, AZ 85734
638-18	First Health, PO Box 535920, Pittsburg, PA 15253-0001
638-20	First Health, PO Box 11950, Coraopolis, PA 15108-6929
638-24	First Health, PO Box 23550, Tucson, AZ 85734
638-25	First Health, PO Box 23070, Tucson, AZ 85734
638-27	First Health, PO Box 11127, Tucson, AZ 85734
638-33	First Health, PO Box 9500, Coraopolis, PA 15108-0000
638-35	First Health, PO Box 11111, Fort Scott, KS 66701
638-45	First Health, PO Box 671128, Houston, TX 77267
638-47	First Health, PO Box 23130, Tucson, AZ 85734-3130
639-02	Highmark Services, PO Box 535078, Pittsburgh, PA 15253-5078
640-00	Harborside Healthcare, PO Box 4925, Lancaster, PA 17604-4925
640-50	Allied Adminstrators, PO Box 2500, San Francisco, CA 94126
641-10	Performax, PO Box 61505, King of Prussia, PA 19406
641-11	Performax, PO Box 1065, Amherst, NY 14226-1065
642-20	Stirling & Stirling Inc., 20 Armory Lane, Milford, CT 06460-3361
643-00	Med Tac, PO Box 9110, Newton, MA 02460
645-50	Brighton Marine, Uniformed Services Family Health, PO Box 9203, Waltham, MA 02172
647-20	Geisinger Health Plan, PO Box 8200, Danville, PA 17821-8200
650-50	Mashantucket Plan Administrators, PO Box 3620, Mashantucket, CT 06339
653-00	American Maritime Officers Medical Plan, PO Box 35, Dania Beach, FL 33004-0035
654-00	ASR Corp, 3033 Orchard Vista Dr SE, Grand Rapids, MI 49546-7000
656-01	Diversified Administration Corp, PO Box 299, 369 N Main St, Marlborough, CT 06447-0299
658-10	Delta USA, PO Box 5402, Lisle, IL 60532-5402
659-04	Zenith Administrators, 161 Forbes Rd, Braintree, MA 02184
659-10	United Chambers, PO Box 3209, Covina, CA 91722
660-10	Presbyterian Health Plan, PO Box 27489, Albuquerque, NM 87125-7489
660-50	Precise Benefits, PO Box 9064, Jericho, NY 11753-8964
661-00	Comprehensive Benefits Service, PO Box 373, 90 S New Towns, Newton Square, PA 19073

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
661-02	CBA Inc, 3800 NW 12th, Suite A, Lincoln, NE 68521
661-05	Comprehensive Benefits Adm, PO Box 2365, 23 Pachen Rd, South Burlington, VT 05407-2365
669-10	American National Health Insurance, PO Box 1520, Galveston, TX 77553
670-02	S & S Healthcare, PO Box 141097, Cinninnati, OH 45250
670-10	Sauder Welfare Trust, PO Box 156, Archbold, OH 43502
675-50	Health Management Center (HMC), PO Box 518, Springfield, MA 01101-0518
678-00	Choice Plus of Vermont, PO Box 6589, Syracuse, NY 13217
680-00	Select Benefit Administrators of America, PO Box 440, Ashland, WI 54806-0440
682-50	American Trust Administrators, PO Box 87, Shawnee Mission, KS 66201
687-00	Employee Benefit Plan Administration - EPBA, PO Box 2000, Exeter, NH 03833-2000
687-02	Employee Benefit Administrators Inc, 64 Schoosett St, Rte 139, Pembroke, MA 02359
687-06	EBMS (Employee Benefit Mgmt Service), PO Box 21367, Billings, MT 59104
690-00	Champion International, Corporate Benefits, Knights Bridge Dr, Hamilton, OH 45020
690-50	Benefirst, 1020 Plain St Suite 220, PO Box 1421, Marshfield, MA 02050
691-00	US Administrators, PO Box 30654, Los Angeles, CA 90030
693-50	UHC Choice Medica, Route 2901, PO Box 169061, Duluth, MN 55816-8310
694-03	Willis of Kansas, Koch Industries Employees, PO Box 2906, Wichita, KS 67201
696-00	Group Health, MSP Unit, 80 Wolf Rd, Albany, NY 12205
696-30	Group Resources Inc, PO Box 100043, Duluth, GA 30096-9343
698-00	Corporate Benefits Services, Armstrong Claims Divsion, 139 S Tryon St 6th Fl, Charlotte, NC
28202
699-00	Firestone Tire and Rubber Benefits, 1200 Firestone Pkwy, Akron, OH 44317
699-02	Bridgestone Firestone, PO Box 26605, Akron, OH 44319
700-06	HPS/Paradigam, PO Box 2530, Tifton, GA 31793-2530
700-11	Protective Dental Care, PO Box 830626, Birmingham, AL 35283-0626
700-15	Complete Care Control Simplex, Simplex Plaza, Gardner, MA 01441
700-37	Montachussett Health Plan, 285 Central St, Leominster Plaza, Leominster, MA 01453
700-71	American Service Life, PO Box 470788, 200 Bailey St, Fort Worth, TX 76147
700-76	Summacare, PO Box 3620, Akron, OH 44309-3620
700-77	Legett & Platt Company, PO Box 757, Carthage, MO 64836
700-80	The Loomis Company, PO Box 7011, Wyomissing, PA 19610-6011
700-81	Group Insurance Service Center, PO Box 9120, Marshfield, MA 02050-9120
700-90	HPN (Health Plan Nevada), PO Box 15645, Las Vegas, NV 89114

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-21	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
701-02	Machigonne Benefit Administrators, PO Box 3859, Portland, ME 04104
701-10	Benefits Management Services, PO Box 1178, Matthews, NC 28106
701-40	APA Partners Inc, 8 British American Blvd, PO Box 1506, Latham, NY 12110-8006
701-80	Ironclad, 161 Granite Ave., Dorchester, MA 02124-5491
702-25	USI Administrators, PO Box 1539, Fort Worth, TX 76101-1539
702-30	CBCA Administrators, PO Box 776, Mellville, NY 11747
702-35	USI Administrators, PO Box 8911, Melville, NY 11747-8911
703-00	MIT Health Plan, 77 Massachusetts Ave, Medical Dept, Cambridge, MA 02139
703-01	Coresource, PO Box 1195, Minneapolis, MN 55440
703-02	Coresource, 146 Industrial Park, Jackson, MN 56143-9439
703-30	Coresource, Inc, 4940 Campbell Blvd, Suite 200, Baltimore, MD 21236
703-40	Coresource, PO Box 168, 4801 Southwick Dr, Matteson, IL 60443-0168
703-45	Coresource, PO Box 6118, Westerville, OH 43086-6118
703-50	Core Source, Inc, 6100 Fairview Rd, Suite 10, Charlotte, NC 28210
703-80	Coresource, PO Box 83301, Lancaster, PA 17608
704-10	Shaw Industries Inc, PO Box 1208, Dalton, GA 30722
705-60	Westport Benefits, PO Box 66743, St Louis, MO 63166
707-00	Catholic Assoc of Foresters, 347 Commonwealth Ave, Boston, MA 02115
712-01	General Electric Pensioners, PO Box 6125, Utica, NY 13504-6125
712-04	GE Group Administrators, PO Box 3005, Agawam, MA 01001
712-05	General Electric Health Care Preferred, PO Box 740801, Atlanta, GA 30374-0801
713-12	GMP Employers Retiree Trust, 5245 Big Pine Way, Ft Myers, FL 33907
714-20	Claims Management Service, PO Box 10888, Green Bay, WI 54307
714-25	Claim Management Services, PO Box 279, West Bend, WI 53095
717-00	Fra Milicare, PO Box 10340, Des Moines, IA 50306-0340
720-20	Q3 Business Tech Corp for Votaw Electric, PO Box 15952, Fort Wayne, IN 46885-5952
722-00	Northeast Delta, 6 London St, Concord, NH 03301
730-50	Babb Inc., 850 Ridge Ave. Ste. 1, Pittsburghpa, PA 15212-6095
734-01	Definity Health, PO Box 9525, Amherst, NY 14226
737-01	Corporate Benefits Service Inc., PO Box 12954, Charlotte, NC 28220-2954
737-03	Corporate Benefits Systems, 139 S Tyron St, Suite 609, Charlotte, NC 28202
737-04	Corporate Benefits Services of America, PO Box 27267, Minneapolis, MN 55427
737-05	Corportate Benefit Service, 145 Scaley Bark, Charlotte, NC 28222

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-22	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
737-06	Corporate Benefits of America, PO Box 2043, Hopkins, MN 55343
743-10	EBPA, 2500 Maitland Center Pkwy, Suite 203, Maitland, FL 32751
744-00	Confederate Administrative Services, 20 William St, Suite 250, Wellesley, MA 02481
749-60	KB Toys Associate Benefit Plan, PO Box 9071, Dublin, OH 43017-0971
750-20	Sieba LTD, PO Box 5000, Endicott, NY 13761-5000
750-30	Retiree Medical Inurance, PO Box 10432, Des Moines, IA 50306-0432
753-01	Eastern Benefits, 200 Freeway Dr E, East Orange, NJ 07019
756-00	Principal Financial Group, 3435 Stelzer Rd, Suite 30, Columbus, OH 43219
756-05	Principal Financial Group, 1 International Plaza, Suite 100, Philadelphia, PA 19113-1510
756-12	Principal Life Insurance, PO Box 10826, Clearwater, FL 33757-8826
756-13	Principal Financial Group, 1245 Corporate Blvd, Suite 200, Aurora, IL 60504
756-70	PHCS/Private Healthcare Systems, PO Box 1934, Des Plaines, IL 60017-1934
756-80	Private Health Care Systems, PO Box 1607, Des Plaines, IL 60017-1607
758-00	Hillcrest Community Health Plan, 1201 Troy Rd, Latham, NY 12110
767-00	Ultra Benefits, PO Box 763, Westboro, MA 01581
774-30	Willis Corroon Insurance, PO Box 2697, Wichita, KS 67201
776-00	Samba, 11301 Old Georgetown Rd, Rockville, MD 20852
783-20	Screen Actors Guild Producers, PO Box 7830, 3601 W Olive Ave, Burbank, CA 91503
783-30	Scott and White Health Plan, 2401 So 31st Street, Temple, TX 76504-7196
800-00	Masters Mates & Pilots Health & Benefit Plan, 5700 Hammonds Ferry Rd, Linthicum Heights,
MD 21090-1996
803-03	Administrators and Consultants, PO Box 4925, Lancaster, PA 17604-4925
803-20	Administrative Enterprises, Inc, 3404 W Cheryl Dr, Suite 281, Phoenix, AZ 85051
804-00	America's Choice Healthplans, PO Box 60432, King of Prussia, PA 19406
805-50	Watkins Assoc Industries, PO Box 1738, Atlanta, GA 30101-1738
810-00	Vanguard Group Inc, 1979 Marcus Ave, Lake Success, NY 11042
813-00	Berkshire Health Plan, 279 Dalton Ave, Pittsfield, MA 01201
816-01	Mediplan, 502 Valley Rd, Wayne, NJ 07410
830-00	Administrative Service Consultants, 3301 E Royalton Rd, Cleveland, OH 44147
830-08	Administrative Service Consultants, PO Box 928, Findlay, OH 45830-0928
832-40	Interactive Corp, PO Box 567, Farmington, CT 06034
839-04	Goodyear Medical Benefit Plan, PO Box 677, Akron, OH 44309
840-20	Alicare, PO Box 1435, New York, NY 10116

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-23	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
840-50	Longview Fibre Company, 1220 SW Morrison, Suite 300, Portland, OR 97205
840-80	Alicare Inc, PO Box 1442, New York, NY 10116
843-40	Mega Life & Health Insurance, PO Box 982009, North Richland Hills, TX 76182-8009
843-45	Mega Life Student Insurance, PO Box 809025, Dallas, TX 75380-9025
844-21	Benesight, PO Box 375, Pueblo, CO 81002-0375
844-22	Benesight/Dental, PO Box 360, Pueblo, CO 81002-0360
844-30	The TPA, Inc., PO Box 7045, Rockford, IL 61125-7045
844-40	Benesight, PO Box 370, Pueblo, CO 81002-0370
863-02	Harrington Benefit Service, PO Box 30367, Tampa, FL 33630
872-10	Advanced Benefit Resources, PO Box 350, Woodbury, NY 11797-0350
872-20	Advanced Administration, 101 North Lake Destiny Rd, Suite 130, Maitland, FL 32751
876-20	Harrington Benefit Services Inc, PO Box 1394, Duncan, OK 73534-1394
886-00	Humana Care Plus, PO Box 2180, Louisville, KY 40202
886-01	Humana Care Plus, PO Box 19080-F, Jacksonville, FL 33245
886-02	Humana Dental, 1100 Employers Blvd, Green Bay, WI 54344
886-05	Humana Claims, PO Box 14610, Lexington, KY 40512-4610
888-10	KPS Health Plans, PO Box 339, Bremerton, WA 98337-0039
891-38	NCAS/National Claims Admin. Service, 7083 Grand National Drive Suite, Orlando, FL 32819
893-00	North Shore Health Plan, 1 Essex Circle Dr, Peabody, MA 01960
893-10	North Shore Health System, PO Box 4445, Salem, MA 01970-6445
895-01	Star Administrative Services, PO Box 55270, Phoenix, AZ 85078
895-02	Managed Care Concepts, 900 Haddon Ave, Suite 304, Collingswood, NY 08108
895-05	Medco Behavioral Care Service, 6 Bedford Farms, Bedford, NH 03110
895-10	Kepple & Company, PO Box 1986, Peoria, IL 65156-1986
895-15	JP Farley, PO Box 268000, Cleveland, OH 44126
895-25	Weyco Inc Benefit Managment, PO Box 30132, Lansing, MI 48909-7632
898-30	Group Administrators, Ltd, 1880 N Roselle Rd, Suite 214, Schaumburg, IL 60195
898-50	Group Benefits Services, 6 North Park Drive, Suite 310, Hunt Valley, MD 21091
900-03	Dow Chemical, Group Insurance Dept, PO Box 1701, Midland, MI 48640
900-32	United Benefits, PO Box 2480, Daytona Beach, FL 32115-2480
900-89	HRM Claim Management, Upjohn Claims, PO Box 4089, Kalamazoo, MI 49003
900-94	Benefit Planners Inc, PO Box 690450, San Antonio, TX 78269
900-96	AFTRA (American Federation TV/Radio), 261 Madison Ave, New York, NY 10016

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-24	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
901-20	Chesterfield Resource, PO Box 1884, Akron, OH 44309
901-26	Atlantic Administrators, 135 Beaver St, Waltham, MA 02452
901-41	Health New England, One Monarch Place, Claims Dept, Springfield, MA 01144-1500
901-51	United Plans, PO Box 9098, 195 Worcester St, Waltham, MA 02254
901-87	Veterans Benefits, 1 Government Center, Fall River, MA 02722
901-92	Frank Heller Associates, 8228 Mayfield Road Suits 5-B, Chesterland, OH 44026-2542
902-14	Hub Folding Box, 774 Norfolk St, Mansfield, MA 02048
903-01	MassHealth/MCO-Fallon Community Health Plan, PO Box 15121, Worcester, MA 01615
903-26	MassHealth/MCO-Neighborhood Health Plan A, 253 Summer St, Boston, MA 02210
903-56	MassHealth/MCO Network Health, Claims Office, PO Box 390310, Cambridge, MA 02139
903-57	MassHealth/MCO Boston Medical Center Health Plan, P O Box 55282, Boston, MA 02205-5282
903-58	MassHealth MCO/BMC HealthNet Plan, PO Box 55282, Boston, MA 02205-5282
905-28	Motorola Inc, PO Box 29005, Phoenix, AZ 85038
905-29	Employers Health Insurance, PO Box 1100, Lincoln National Co, Green Bay, WI 54344
905-80	National Automatic Sprinkler (Self-Insured), 800 Corporate Dr, Landover, MD 20785
905-82	Administration & Insurance Office, PO Box 12245, Portland, OR 97212
905-95	Freedom Care Health Plan, 222 Boylston St, Boston, MA 02109
906-20	NGS American Inc, PO Box 7676, Saint Claire Shores, MI 48081
906-45	Colonial Benefit Insurance Admin, PO Box 3770, 8540 Ashwood Dr, Capital Heights, MD 20743
906-49	Strategic Resource Company (SRC), PO Box 23759, Columbia, SC 29224-3759
906-81	Health Plan Inc, PO Box 15100, Worcester, MA 01615
906-87	Automated Benefit Services, PO Box 37506, Oak Park, MI 48237-0506
906-89	Inter-Care, PO Box 3559, Englewood, CO 80155
908-55	Accordia National, PO Box 11522, Charlestown, WV 25339
908-58	Benefit Administrator, 1745 Jovanna Dr #1b, Homewood, IL 60430
908-64	Gallagher Bassett Services, PO Box 5227, Lisle, IL 60532
908-67	Gallagher Benefit Services, Department 5010, PO Box 162721, Austin, TX 78716
910-07	HMO Rhode Island, 30 Chestnut St, Providence, RI 02903
910-10	Neighborhood Health Plan, 253 Summer St, Boston, MA 02210
913-00	East Boston Geriatric Services, 10 Gove St, Elder Service Plan, Boston, MA 02128
913-03	Cambridge Hosp ESP, 270 Green St, Cambridge, MA 02139
913-04	ESP of the North Shore, 20 Market St, Lynn, MA 01901
913-05	ESP of Mutual Healthcare, 1140 Dorchester Ave, Dorchester, MA 02125

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-25	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
913-06	ESP Harbor Health Services, 2216 Dorchester Ave, Dorchester, MA 02124
914-00	Hospice Program. Bill hospice provider if service is related.
920-00	Self -Reported Insurance. Ask member for a copy of the insurance card.
953-00	Hebrew Rehab Center, 1200 Centre St, Roslindale, MA 02131
962-01	Adventist Risk Management, PO Box 4759, Silver Spring, MD 20914-4759

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
APPENDIX C: THIRD-PARTY-LIABILITY CODES	PAGE
C-26	

	TRANSMITTAL LETTER
ALL-114	DATE
05/01/03	
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