Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington StreetBoston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER ALL-131 June 2005 TO: All Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director 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: MassHealth 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 MassHealth Web site at www.mass.gov/masshealth. 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 through June 30, 2005, 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 After June 30, 2005, to request a paper copy of Appendix C, call 1-800-841-2900, or e-mail your request to publications@mahealth.net, or fax to 617-988-8973. Please include your provider number, address, and telephone number with your request. MASSHEALTH TRANSMITTAL LETTER ALL-131 June 2005 Page 2 NEW MATERIAL (The pages listed here contain new or revised language.) All Provider Manuals Pages C-1 through C-30 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Pages C-1 through C-26 — transmitted by Transmittal Letter ALL-114 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-1 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-131 DATE 07/01/05 THIRD-PARTY-LIABILITY CODES Important Note: A searchable version of this appendix is available on the MassHealth Web site at www.mass.gov/masshealth. MassHealth will update Appendix C as needed. Paper copies of this appendix will not be mailed automatically, but can be requested by calling 1-800-841-2900, or by e-mailing your request to publications@mahealth.net, or by fax to 617-988-8973. 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. 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 you use the MassHealth Recipient Eligibility Verification System (REVS) Automated Voice Response (AVR) system, you will be given the following TPL coverage-type code. If you use a REVS POS device, WebREVS, or electronic transactions, you will receive a full description of the coverage type instead of a code. Code TPL Coverage-Type Description Code TPL Coverage-Type Description 01 Hospital Services 23 Managed Care HMO Senior Plans w/Pharmacy 02 Comprehensive Indemnity 24 Managed Care HMO Senior Plans w/o Pharmacy 04 Medicare A 25 MCO/DSS Children with Special Needs 05 Medicare B 26 Mental Health Services Program for Youth 06 Medicare Supplement 27 Preferred Physician Program 08 Nursing Home Care 31 Blue Master Health Plus 09 HMO without Mental Health 32 Hospice Program 10 Hospital Confinement Indemnity 33 Federal BC/BS Medigap Policies 11 Health Maintenance Organization 34 PACE (On Lok) 12 Vision Care* 35 Commercial Insurance w/o Mental Health 13 Dental Care* 36 On Lok w/Coinsurance and Deductible 14 Preferred Provider Organization 37 Senior Care Options 15 CHAMPUS or CHAMPVA 53 Hebrew Rehabilitation 16 Medicare Part A Medigap 55 Youville w/Crossover 17 Pharmacy – Cost Avoidance* 56 HMO Senior Plans 18 Pharmacy Coverage – Pay and Chase* 57 Long Term Care HMO Senior Plans 19 MassHealth MCO w/Pharmacy 63 Veterans Services (Non-Comprehensive) 20 MassHealth MCO w/o Pharmacy 64 Veterans Services (Comprehensive) 21 Special Populations with Pharmacy 22 Neighborhood Health Plan * If a member has dental, vision, or pharmacy coverage only, then the member can be enrolled in a managed care program. II. CARRIER CODES The following is a list of carrier codes and the names and addresses of the insurance companies to which they refer. You will see these codes no matter what REVS or billing method you use. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-2 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 001-10 Evercare Senior Care Options, 275 Grove St, Auburndale, MA 02466-2274 001-11 Commonwealth Care Alliance SCO, 30 Winter St, Boston, MA 02108 001-13 Senior Whole Health SCO, 101 Rogers St, Suite 207, Cambridge, MA 02142 017-05 Medical Benefits Administrators Inc, PO Box 209, Newark, OH 03058-0209, (781)762-5511 027-00 Blue Cross Blue Shield of Massachusetts, PO Box 9197, North Quincy, MA 02171, (800)451-8123 027-02 Blue Cross Blue Shield of Massachusetts Medex, PO Box 9196, Boston, MA 02105, (800)451-8123 027-03 Blue Cross Blue Shield of Massachusetts Medex - Gold, PO Box 9196, Boston, MA 02105, (800)451-8123 027-25 Blue Cross Blue Shield Dental, PO Box 9157, North Quincy, MA 02171, (800)882-1178 027-26 Blue Cross Blue Care 65, PO Box 9201, North Quincy, MA 02171, (800)451-8123 027-33 Blus Cross Dental of Rhode Island, PO Box 219, Providence, RI 02901-0219, (800)676-2583 027-34 Blue Cross Blue Shield of Texas Dental, PO Box 660247, Dallas, TX 75266-0247, (800)521-2227 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, (207)775-1550 027-46 Anthem Blue Cross Blue Shield of New Hampshire, 3000 Goffs Fall Rd, Manchester, NH 03111, (800)332-6558 027-48 Blue Shield of Northeastern New York, PO Box 15013, Albany, NY 12212-5013, (800)444-9940 027-49 Empire Blue Cross Blue Shield of New York, PO Box 11800, Albany, NY 12211, (518)367-4737 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, (518)367-4737 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, (800)635-2184 027-67 Empire Blue Cross Blue Shield, PO Box 420, Murray Hill Station, New York, NY 10156, (518)367-4737 027-68 Empire Blue Cross Blue Shield of NY, PO Box 1407, Church Station, New York, NY 10008-1407, (212)476-7111 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, (518)367-4737 027-74 Empire Blue Cross Blue Shield, PO Box 399, Grand Central Station, New York, NY 10156, (518)367-4737 027-77 Empire Blue Cross Blue Shield, PO Box 170, New York, NY 10156, (518)367-4737 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-3 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 027-80 Blue Cross Blue Shield of Alabama, PO Box 360508, Birmingham, AL 35236-0508, (800)334-9041 028-00 Blue Cross Blue Shield of Michigan, 600 Lafayette E, Detroit, MI 48226, (800)637-2227 028-04 Anthem Dental of CT, PO Box 50047, North Haven, CT 06473, (888)799-6290 028-05 Blue Cross of California, PO Box 60007, Los Angeles, CA 90060, (800)333-3888 028-07 Blue Cross Blue Shield of Florida, Columbia Svc Ctr, PO Box 100121, Columbia, SC 29202-3121 028-08 Carefirst Blue Cross Blue Shield, 550 12th St SW, Verizon, Washington, DC 20065-0001, (800)642-2411 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, (800)241-5703 028-11 Blue Cross Blue Shield of Florida, 532 Riverside Ave, PO Box 1798, Jacksonville, FL 32231, (800)727-2227 028-13 Blue Cross Blue Shield of Georgia, 2357 Warm Springs Rd, PO Box 7368, Columbus, GA 31908 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, (800)730-8434 028-22 Blue Cross Blue Shield of Indiana, 5451 Lakeview Pkwy, Indianapolis, IN 46268 028-23 BC Life and Health, PO Box 9201, Oxnard, CA 93031, (800)627-0004 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, (800)624-1110 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, (800)358-0050 028-32 Carefirst Blue Cross Blue Shield, PO Box 812, Owings Mills, MD 21117-0812, (800)843-4280 028-33 Horizon BC/BS of New Jersey, PO Box 1609, Newark, NJ 07101, (800)414-7427 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, (405)787-6020 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, PO Box 1219, Newark, NJ 07101 028-39 Anthem Blue Cross and Blue Shield, 2 Gannett Drive, South Portland, ME 04106-6911, (207)822-7000 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-4 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 028-41 Anthem Blue Cross Blue Shield, PO Box 37690, Louisville, KY 40233-7690, (866)755-2657 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 028-57 Blue Cross Blue Shield Dental of Rhode Island, PO Box 219, Providence, RI 02901 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, (800)637-3718 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, (972)766-6900 028-68 Trigon Blue Cross Blue Shield, 2015 Staples Mill Rd, PO Box 27401, Richmond, VA 23279, (804)358-1551 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, (203)239-4911 028-94 Blue Cross Blue Shield of Texas, PO Box 660044, Dallas, TX 75266-0044, (800)521-2227 028-95 Trigon Blue Cross Blue Shield, PO Box 27287, Richmond, VA 23261-7287, (804)354-7000 058-15 Dental Benefit Providers, PO Box 30640, Bethesda, MD 20824-4814, (800)445-9090 064-00 Delta Dental of California, PO Box 7736, San Francisco, CA 94120-7736, (888)335-8227 064-01 Champus/Tricare Military Health Systems, PO Box 870140, Camden, SC 29587-9740, (866)773-0404 064-02 Delta Dental of Rhode Island, Blue Cross Blue Shield, PO Box 1517, Providence, RI 02901, (401)752-6100 064-03 Delta Dental Plan of Michigan, PO Box 9085, Farmington Hills, MI 48333 064-05 Delta Dental, PO Box 828, Stevens Point, WI 54481 064-08 Sierra Military Health Services, Tricare for Life, PO Box 7889, Madison, WI 53707, (866)835-7422 064-11 Delta Dental of Colorado, PO Box 173803, Denver, CO 80217 064-14 Delta Dental Plan of Minnesota, PO Box 59238, Minneapolis, MN 55459-0238 064-15 Delta Dental of Pennsylvania, 1 Delta Drive, Mechanicsburg, PA 17055, (800)932-0783 064-16 Delta Dental Plan of Ohio, PO Box 9785, Farmington Hills, MI 48333-9785 064-20 Delta Dental of Kentucky, PO Box 242810, Louisville, KY 40224-2810, (800)955-2030 064-25 Delta Dental of VA, 4818 Starkey Rd, Roanoke, VA 24014 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-5 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 064-30 Delta Dental Plan of Arkansas, 100 Shadow Oaks Dr, PO Box 15965, North Little Rock, AR 72231-5965, (800)462-5410 064-31 Delta Dental of Texas, PO Box 1809, Alpharetta, GA 30023-1809, (800)521-8700 064-35 Delta Dental Plan of New Jersey, PO Box 222, Parsippany, NJ 07054, (800)452-9310 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, (888)999-5195 083-00 Delta Dental Plan of Massachusetts, PO Box 9695, Boston, MA 02114-9695, (800)451-1249 084-00 Medicare A Claims 085-00 Medicare B Claims 091-01 Fallon Community Health Plan, Senior, Claims Dept, PO BOX 15121, Worcester, MA 01615-0121, (800)333-2535 091-05 Fallon Community Health Plan, PO Box 15121, Claims Division, Worcester, MA 01615-0121, (800)868-5200 092-00 Harvard Pilgrim Health Care, PO Box 699183, Quincy, MA 02269-9183, (888)888-4742 092-12 Harvard Community Health, First Seniority, PO Box 699183, Quincy, MA 02269-9183, (800)742-8326 095-00 Matthew Thornton Health Plan, PO Box 9514, Manchester, NH 03108 101-01 Tufts Health Plan, PO Box 9163, Watertown, MA 02471-9163, (800)462-0224 101-02 Tufts Secure Horizons Claims Dept, PO Box 9183, Watertown, MA 02471-9183, (800)279-9022 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, (800)292-4366 106-01 Aetna/US Healthcare, PO Box 1858, 1800 E Interstate Ave, Bismark, ND 58502, (800)624-0756 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, (800)248-3132 106-05 Aetna/US Healthcare, 3 Burlington Woods Dr, Burlington, MA 01830, (800)323-9930 106-06 Aetna/US Healthcare, 3541 Winchester Rd, Allentown, PA 18195, (800)292-4366 106-07 Aetna/US Healthcare, PO Box 1125, Blue Bell, PA 19422-0770, (800)624-0756 106-08 Aetna/US Healthcare, PO Box 2295, Fort Wayne, IN 46801 106-09 Aetna/US Healthcare, PO Box 31450, Tampa, FL 33636 106-11 Aetna/US Healthcare, PO Box 24024, Fresno, CA 93779, (800)354-5835 106-14 Aetna/US Healthcare, PO Box 3909, Allentown, PA 18106-0909, (610)336-1000 106-18 Aetna/US Healthcare, PO Box 150417, Hartford, CT 06115-0417, (800)872-3862 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, (800)323-9930 106-30 Aetna/US Healthcare, PO Box 44128, Jacksonville, FL 32231-4128, (877)580-5018 106-31 Aetna/US Healthcare, PO Box 981107, El Paso, TX 79998-1107, (800)245-6738 106-34 Aetna/US Healthcare, 10101 Reunion Place, PO Box 28060, San Antonio, TX 78228, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-6 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (800)587-3496 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, (800)354-5835 106-38 Aetna/US Healthcare, PO Box 18040, Columbus, OH 43218-0040, (614)933-6000 106-44 Aetna/US Healthcare, PO Box 7064, Dover, DE 19903-1512 106-45 Aetna/US Healthcare, PO Box 26106, Greensboro, NC 27402-6106, (800)844-5562 106-47 Aetna/US Healthcare, 3875 Embassy Pkwy, PO Box 5569, Akron, OH 44334, (800)570-6874 106-52 Aetna /US Healthcare, PO Box 91522, Arlington, TX 76015-0022, (800)872-3862 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, (800)248-3132 106-61 Aetna/US Healthcare, PO Box 3925, Allentown, PA 18106, (800)292-4366 106-62 Aetna/US Healthcare, PO Box 1630, Columbus, OH 43216, (800)833-0220 106-63 Aetna/US Healthcare, PO Box 14014, Lexington, KY 40512, (877)362-0869 106-64 Aetna/US Healthcare, PO Box 26103, Greensboro, NC 27402 106-65 Aetna/US Healthcare, P O Box 2520, Tyler, TX 75710-2520, (800)441-1864 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, (877)235-4005 106-71 Aetna/US Healthcare, PO Box 52120, Minneapolis, MN 55402-5120, (800)445-0128 106-72 Aetna/US Healthcare, Loop Statiom, PO Box 2907, Minneapolis, MN 55402-0907, (800)872-3862 106-73 Aetna/Us Healthcare, 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 106-79 Aetna US Healthcare, PO Box 14586, Lexington, KY 40512-4586, (877)362-0869 106-80 Aetna/US Healthcare, PO Box 1214, Tewksbury, MA 01876, (888)802-3862 106-83 Aetna/US Healthcare, PO Box 14089, Lexington, KY 40512-4089, (800)872-3862 106-87 Aetna/Us Healthcare, PO Box 2950, Loop Station, Minneapolis, MN 55402-000, (800)589-4811 106-92 Aetna/US Healthcare, PO Box 14094, Lexington, KY 40512-4094, (877)368-6605 106-96 Aetna/US Healthcare, PO Box 981106, EL Paso, TX 79998-1107, (888)891-0756 106-97 Aetna/US Healthcare, PO Box 129010, San Diego, CA 92112, (800)814-3543 106-98 Aetna Dental, PO Box 14027, Lexington, KY 40512-0000 106-99 Aetna/US Healthcare, 3 Centerview Dr, PO Box 26190, Greensboro, NC 27402 112-15 Allstate Workplace Division, 1776 AHL Dr, Jacksonville, FL 32224 122-05 AFLAC, 1932 Wynnton Rd, Columbus, GA 31999 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 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-7 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 01845 138-10 Amerihealth Administrators, 720 Blair Mill Road, Horsham, PA 19044-2269, (800)492-2385 138-45 Americ Ben Solutions, PO Box 7186, Boise, ID 83707-1186, (800)786-7930 143-04 AVMA, PO Box 909720, Chicago, IL 60690-9720, (800)621-6360 144-40 Ameritas Life Insurance, PO Box 82520, Lincoln, NE 68501, (800)487-5553 149-16 Associated Plan Admin, PO Box 189, Columbus, OH 43216 149-18 Associated Plan Admin, PO Box 9568, New Haven, CT 06535, (203)287-1272 154-10 Bankers Life and Casualty, PO Box 66927, Chicago, IL 60666-0927, (800)621-3724 160-01 BCI Administrators, PO Box 251568, West Bloomfield, MI 48325-1568, (248)626-8896 167-00 Boston Mutual Life Insurance, 120 Royall St, Canton, MA 02021 171-00 Washington National, PO Box 1250, Rockford, IL 61105, (815)987-0409 171-01 Washington National, Health Claims Dept, 399 Market St, Philadelphia, PA 19181-1250, (800)523-4000 171-05 Capital District Physicians Health Plan, PO Box 66602, Albany, NY 12206-6602, (800)926-7526 171-15 Capitol Administrators, PO Box 2318, Rancho Cordova, CA 95741 172-07 Celtic Life Insurance, PO Box 06401, Chicago, IL 60606-6393 176-00 Central States Health and Life of Omaha, PO Box 34350, Omaha, NE 68134 178-00 21st Century Health and Benefits, PO Box 5037, Cherry Hill, NJ 08034-0367, (800)533-9323 183-50 Chickering Claim Administrators Inc, PO Box 410378, Cambridge, MA 02141, (877)480-4167 184-05 Cherokee Insurance, PO Box 159, Warren, MI 48090, (800)201-0450 184-10 Christian Brothers Health Management Services, 1205 Windham Parkway, Romeoville, IL 60446-1672, (630)378-2900 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, (800)225-4500 194-10 Combined Benefit Administration, 4704 W Jennifer Ave, Suite 104, Fresno, CA 93722 198-00 Commercial Union Insurance Company, One Beacon St, Boston, MA 02108 200-00 Cigna, PO Box 8012, Plainville, CT 06062, (800)244-6224 200-02 Cigna Healthcare, PO Box 5067, Visalia, CA 93279 200-03 Cigna, PO Box 2083, Concord, NH 03302-2083, (603)268-7000 200-05 Cigna Healthcare, PO Box 5087, Southfield, MI 48086, (248)354-8330 200-06 Cigna Health Plan, PO Box 188002, Chattanooga, TN 37422-8002, (800)433-3926 200-08 Cigna Healthcare, PO Box 5200, Scranton, PA 18505-5200, (800)244-6224 200-10 Cigna, PO Box 5019, Visalia, CA 93278, (559)738-2000 200-11 Cigna, PO Box 3077, Bourbonnais, IL 60914, (800)541-7526 200-12 Connecticare, PO Box 546, Farmington, CT 06034-0546, (800)251-7722 200-14 Cigna, PO Box 2546, Sherman, TX 75091 200-16 Cigna Healthcare, PO Box 10485, Des Moines, IA 50306-0485, (800)223-9601 200-18 Connecticut General Life Insurance, PO Box 2316, 4 Gateway Center, Suite 6, Pittsburgh, PA Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-8 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 15230 200-19 Cigna, PO Box 49400, Atlanta, GA 30359 200-20 Cigna Healthcare, Station B, PO Box 6185, Greenville, SC 29605-6185, (800)654-4209 200-21 Cigna, PO Box 24009, Fresno, CA 93779 200-22 Cigna Healthcare, PO Box 34335, Charlotte, NC 28244, (800)462-2135 200-23 Cigna, PO Box 1970, Bourbonnais, IL 60914, (800)541-7526 200-26 Cigna, PO Box 8013, Plainville, CT 06062, (800)462-7486 200-29 Cigna Healthcare, PO Box 182532, Columbus, OH 43218, (800)722-7535 200-33 Cigna, PO Box 5046, Southfield, MI 48086, (800)523-4626 200-36 Cigna Healthcare, PO Box 15538, Wilmington, DE 19850-5538 200-37 Cigna PPO High, 900 Cottage Grove Rd, Suite C304, Hartford, CT 06152 200-38 Cigna, PO Box 182014, Columbus, OH 43218 200-39 Cigna Healthcare, PO Box 3087, Bourbonnais, IL 60914, (800)345-9458 200-40 Cigna Healthcare, PO Box 5353, Melville, NY 11747-5353 200-41 Cigna, PO Box 3040, Bourbonnais, IL 60914, (800)541-7526 200-42 Cigna, PO Box 2100, Bourbonnais, IL 60914, (800)541-7526 200-43 Cigna, PO Box 964, Bristol, CT 06011-0964, (800)345-9458 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, (800)345-9458 200-49 Cigna, PO Box 2005, Farmington, CT 06034, (800)832-3211 200-50 Cigna Dental, PO Box 15558, Wilmington, DE 19850, (800)441-7150 200-52 Cigna Healthcare, PO Box 188008, Chattanooga, TN 37442-0000, (800)304-4436 200-54 Cigna Healthcare, PO Box 1269, Farmington, CT 06034-1269 200-55 Cigna Healthcare, PO Box 188024, Chattanooga, TN 37422, (800)433-3926 200-61 Cigna PPA, PO Box 188007, Chattanooga, TN 37422-8007, (800)541-6980 200-62 Cigna Health Plan of Massachusetts, PO Box 5023, Hartford, CT 06102, (800)462-2135 200-64 Cigna Behavioral Health, PO Box 46270, Eden Prairie, MN 55344-2970, (800)442-4227 200-67 Cigna, PO Box 188004, Chattanooga, TN 37422-8004, (800)251-0670 200-68 Cigna, PO Box 188031, Chattanooga, TN 37422 200-70 Cigna, PO Box 800, Unionville, CT 06085, (800)345-9458 200-72 Cigna, PO Box 188031, Chattanooga, TN 37422, (800)433-3926 200-74 Cigna, PO Box 33668, Charlotte, NC 28233 200-75 Cigna Dental, PO Box 188003, Chattanooga, TN 37422-8003, (800)433-3926 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 354, Avon, CT 06001-0354, (800)832-3211 200-81 Cigna, PO Box 9155, Des Moines, IA 50306, (800)223-9601 200-82 Cigna Dental Health, PO Box 4630, Miami, FL 33269 200-83 Cigna Dental, PO Box 969, Bristol, CT 06010, (800)577-0576 200-85 Connecticut General, PO Box 850, JFK Airport Station, Jamaica, NY 11430 200-86 Cigna, PO Box 29000, Atlanta, GA 30359-9000, (404)681-7000 200-87 Cigna Dental, PO Box 189060, Plantation, FL 33318, (800)342-5234 200-89 Cigna Healthcare, PO Box 182223, Chattanooga, TN 37422-0000, (800)242-6224 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, (800)251-0670 200-95 Cigna Healthcare, PO Box 188009, Chattanooga, TN 37422-000, (800)251-0670 200-96 Cigna Preferred, PO Box 71203, San Juan, PR 00936-8703, (800)453-4187 200-97 Cigna, PO Box 49410, Atlanta, GA 30359-1410, (800)526-5481 200-98 Cigna Healthcare, PO Box 188030, Chattanooga, TN 37422, (800)251-0669 203-00 Consolidated Health Plans, 195 Stafford St, Springfield, MA 01124-3500 203-01 Constitution Health Network, PO Box 720, North Haven, CT 06473 210-02 Crown Cork and Seal, 155 Shepard St, Lawrence, MA 01843 214-01 Cypress Benefit Administrators, PO Box 7020, Appleton, WI 54912, (877)236-0844 215-05 Doc First, PO Box 17098, Owings Mills, MD 21117 226-31 The Equitable, PO Box 3000, Lancaster, SC 29721-3000, (800)782-9355 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, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-9 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-10 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (800)821-7303 247-05 Pro-Net, PO Box 101387, Fort Worth, TX 76185-1387, (800)344-5822 253-60 Fortis Benefits Insurance, PO Box 624, Milwaukee, WI 53201, (800)444-6254 253-80 Fortis Dental, PO Box 2940, Clinton, IA 52733 260-00 Gerber Life Insurance, 204 W Main St, Freemont, MI 49412, (800)253-3074 262-00 Global Exchange, PO Box 823067, South Florida, FL 33082-3067, (800)468-7648 265-00 Golden Rule Insurance, 712 Eleventh St, Lawrenceville, IL 62439, (618)943-8000 265-01 Golden Rule Insurance, 7440 Woodland Dr, Golden Rule Bldg, Indianapolis, IN 46278, (800)265-7791 266-01 Government Employees Hospital Assoc, PO Box 4665, Independence, MO 64051, (800)821-6136 275-00 Great West Health Care, 850 Concord Pkwy, Suite 200, Maitland, FL 32751 275-15 Great West Healthcare, 1000 Great West Drive, Kennett, MO 63857-3749, (800)441-3234 275-18 Great West Life/One Health Plan, PO Box 11111, Fort Scott, KS 66701, (800)663-8081 280-00 Guardian Short Term Disability, PO Box 26160, Lehigh Valley, PA 18002-6160, (800)268-2525 280-06 The Guardian, PO Box 9128, Norwell, MA 02061 280-08 Guardian, PO Box 8019, Appleton, WI 54913, (920)749-9200 280-32 Guardian Life, PO Box 8024, Appleton, WI 54912, (800)695-4542 280-33 Guardian Dental, PO Box 2459, Spokane, WA 99210-2459, (800)541-7846 280-35 Guardian, PO Box 424, East Bridgewater, MA 02333-0424, (800)524-4542 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, (800)441-5741 288-25 Healthnet PPO, PO Box 10223, Van Nuys, CA 91410-0223, (800)641-7761 288-26 Health Net, PO Box 14702, Lexington, KY 40512, (800)861-7214 288-30 Health Partners, PO Box 5194, New York, NY 10185-5191, (215)849-9606 288-35 Health Plans Inc, PO Box 5199, Westborough, MA 01581, (508)752-2480 290-50 Boon-Chapman, PO Box 9201, Austin, TX 78766, (800)252-9653 292-03 Anthem/Home Life Insurance, PO Box 1326, Piscataway, NJ 08855-1326 295-00 IDS Life Insurance, IDS Tower 10, Minneapolis, MN 55440 300-20 Independent Health, PO Box 1430, Buffalo, NY 14231, (877)593-3250 301-01 Insurance Company of North America, 3 Center Plaza, Boston, MA 02108 304-00 Inter Americas Insurance Corporation, PO Box 9510, Wichita, KS 67277-0510, (316)794-2200 304-50 P5 E Health Services, PO Box 9554, Salt Lake City, UT 84109-0554, (800)569-9503 305-02 Intercounty Hospital Plan, 720 Blair Mill Road, Horsham, PA 19044-2269, (800)492-2385 307-10 International Benefit Adm, 7083 Grand National Dr, Suite 104, Orlando, FL 32819 313-03 John Alden, PO Box 1599, Boise, ID 83701-1599, (800)328-4316 313-04 John Alden Life Insurance, PO Box 4243, Woodland Hills, CA 91365-4243, (888)503-8104 313-05 John Alden, PO Box 4243, Woodland Hills, CA 91365-4243 314-00 John Deere Insurance, 3800 Ave of the Cities, 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 315-10 John Hancock Mutual Life Insurance, Pleasant Hill Group Claim, 399 Taylor Rd, Pleasant Hill, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-11 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE CA 94523 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, (800)442-9300 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, (847)706-4050 315-30 Unicare, PO Box 4109, Woodland, CA 91365 315-31 Unicare, PO Box 7062, Schaumburg, IL 60168-4062, (800)258-5284 315-32 Unicare, PO Box 4069, Schaumburg, IL 60168-4069, (800)258-5284 315-35 Unicare, GIC Indemnity Plan, PO Box 9016, Andover, MA 01810, (800)442-9300 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, (800)288-8630 315-52 Unicare, PO Box 51990, Indian Orchard, MA 01151, (413)858-5000 315-55 Unicare Dental, PO Box 9201, Oxnard, CA 91331-9201, (800)627-0004 315-57 Unicare, PO Box 51130, Springfield, MA 01151-5130, (800)288-8630 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, (800)333-3304 315-79 Unicare Compaq Claims, PO Box 833895, Richardson, TX 75083-895, (800)342-0000 315-90 Unicare, PO Box 51180, Indian Orchard, MA 01551-5180, (800)442-9300 315-92 Unicare, PO Box 061109, Chicago, IL 60606-1109, (800)438-6105 315-95 Unicare, PO Box 4061, Schaumburg, IL 60168-4061, (800)304-7258 316-00 Klais & Company, 1867 W Market St, Akron, OH 44313 318-00 Keystone Provident Life Insurance, 99 High St, Boston, MA 02105 318-20 Key Benefit Administrators, PO Box 55210, Indianapolis, IN 46205-0210, (800)871-2335 320-00 Liberty Life Assurance of Boston, 175 Berkeley St, Boston, MA 02117 322-04 Awane Benefit Plan Management, PO Box 536, Rockland, MA 02370-0536, (603)924-9449 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, Wyomissing, PA 19610-6011, (610)374-4040 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 349-00 Medico Life Insurance, 1515 South 75th St, Omaha, NE 68124 349-80 Medspan, Inc, PO Box 340950, Hartford, CT 06134-0950, (860)541-6789 351-00 Metropolitan Life Insurance, Claims, 1 Madison Ave, New York, NY 10010, (800)848-8406 351-01 United Healthcare/Metrahealth, Multicase Svs, PO B30555, Salt Lake City, UT 84130-0555, (877)842-3210 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, (800)988-8333 351-04 United Health Care Dental, PO Box 30650, Bethesda, MD 20824 351-05 United Healthcare, PO Box 1600, Kingston, NY 12402, (800)942-4640 351-06 Metropolitan Life Insurance, c/o Kanawha, Lancaster, SC 29721 351-07 Metropolitan Life Insurance, Group Health Claims, 700 Quaker Lane, PO Box 300, Warwick, RI Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-12 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-13 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 02887 351-12 Metropolitan Life Insurance, Group Claims Office, 9797 Springboro Pike, Dayton, OH 45448, (800)260-1093 351-15 Metropolitan Life Insurance, Bldg 14, The Atrium, PO Box 8555, Philadelphia, PA 19101 351-16 United Healthcare, PO Box 740801, Atlanta, GA 30374, (800)848-8406 351-17 United Healthcare, Verizon Claim Service Center, PO Box 740803, Atlanta, GA 30374-0803, (800)334-4515 351-18 United Healthcare, PO Box 740800, Atlanta, GA 30374-0800, (877)842-3210 351-20 United Healthcare, PO Box 730, Pueblo, CO 81002 351-21 Metropolitan, 615 E Michigan St, Milwaukee, WS 53802 351-24 United Healthcare, PO Box 740802, Atlanta, GA 30374-0802, (800)577-8567 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 351-34 Metropolitan, PO Box 468, Warwick, RI 02887 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, (800)556-3490 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, (800)393-0993 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 351-63 United Healthcare Dental, PO Box 30567, Salt Lake City, UT 84130-0000, (877)816-3596 351-64 United Health Care, PO Box 30551, Salt Lake City, UT 84130-0551, (877)842-3210 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, (877)842-3210 351-83 Metropolitan, PO Box 450, Warwick, RI 02887 351-84 United Healthcare, PO Box 659744, San Antonio, TX 78265-9744, (800)526-2414 351-86 Metropolitan, PO Box 6017, Newark, DE 19714 351-88 Metropolitan Life Dental Claims, PO Box 2579, Pittsburgh, PA 15230 351-92 Metropolitan Life, PO Box 3012, Utica, NY 13504 351-95 United Healthcare, PO Box 30755, Salt Lake City, UT 84130, (800)357-0978 351-98 United Healthcare, 601 Brooker Creek Blvd, Oldsmar, FL 34677 351-99 Metropolitan Life, Dental Benefits Claims C, PO Box 8740, Dayton, OH 45401, (877)638-3379 352-11 United Concordia, UCCI PO Box 69421, Harrisburg, PA 17106-9421, (866)408-4548 352-12 United Concordia, PO Box 69421, Harrisburg, PA 17106-9421, (800)235-1847 354-00 Michigonne Benefit Administrator, PO Box 3859, Portland, ME 04104, (800)245-3529 357-10 Midwest National Life Insurance, PO Box 982017, North Richland Hills, TX 76182-8017, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-14 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (800)733-8880 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, (800)316-7518 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 367-10 Mutual Protection/Medico Life, PO Box 3735, Omaha, NE 68103 371-00 National Elevator Industries, PO Box 477, Newtown Sq, PA 19073, (800)252-4611 374-00 National Financial Insurance, 110 W 7th St, Fort Worth, TX 76102, (800)725-1407 376-03 National Health Insurance, PO Box 619999, Dallas/Ft Worth Airport, TX 75261-6199, (800)237-1900 378-00 Peoples Benefit Life Insurance Company, Claims Department, Valley Forge, PA 19493-0001, (610)648-5000 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, (800)654-1731 388-12 New England Financial, PO Box 7000, Coraopolis, PA 15108 388-16 Unum Provident Corporation, 18 Chestnut St, Worcester, MA 01608-1528, (508)799-4441 388-35 New England Financial/One Health, PO Box 30466, Tampa, FL 33630, (800)654-1731 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 390-20 New York Life Insurance, PO Box 30769, Jamaica, NY 11430 390-35 New York Life, 8834 Capital of Texas Hwy N, Suite 300, Austin, TX 78759, (800)723-5555 394-01 Trans America Insurance Company, PO Box 982009, North Richland Hills, TX 76182-8009, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-15 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (800)527-2845 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, (800)423-6011 398-40 State of North Carolina Teacher and 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, (800)888-7202 414-00 Oxford Life Insurance, 2721 N Central Ave, Phoenix, AZ 85004 414-01 Oxford Life Insurance Company, PO Box 46518, Madison, WI 53744-6518, (877)469-3073 414-02 Oxford Health Plan, PO Box 7082, Bridgeport, CT 06601-7081, (800)444-6222 414-03 Oxford Health Plan, PO Box 2083, Nashua, NH 03061 416-01 Pacific Fidelity Insurance, PO Box 1038, Hurst, TX 76053 418-02 Pacific Mutual, 100 West Claredon, Suite 2000, Phoenix, AZ 85026 418-06 Pacific Life and Annuity Company, PO Box 34799, Phoenix, AZ 85067-4799, (800)733-2285 421-00 Primary Physician Care, 1515 Mockingbird Lane, Charlotte, NC 28220-1088 425-20 Pennsylvania Employee Benefit Trust, 150 S 43rd St, Suite 1, Harrisburg, PA 11711-5708, (717)561-4750 430-00 Phoenix Insurance, One Tower Sq, Hartford, CT 06115 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, (800)451-2513 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, (800)794-5907 432-00 Physicians Mutual Insurance, PO Box 2018, Omaha, NE 68103-2018, (800)228-9100 432-30 Pine Health Benefits, PO Box 2160, Natick, MA 01760 433-01 Pioneer Management Systems, PO Box 6600, Holyoke, MA 01040, (800)423-4586 433-02 Pioneer Life Insurance, PO Box 5151, Janesville, WI 53547-5151, (800)759-7007 435-00 Pinkerton, Ultralink (TPA), PO Box 5049, Costa Mesa, CA 92628 435-05 PPO NEXT, PO Box 2000-214, Mission Viejo, CA 92692, (800)800-7616 439-00 Cigna, PO Box 188036, Chattanooga, TN 37422 439-01 Cigna Health Care, PO Box 188021, Chattanooga, TN 37422-8021, (800)433-3926 439-04 Connecticare, PO Box 522, Farmington, CT 06032 439-07 Connecticare, 30 Batterson Park Rd, Farmington, CT 06032 439-25 Cigna Pharmacy, PO Box 3598, Scranton, PA 18505 439-31 Health Source, PO Box 190023, North Charleston, SC 21419 439-55 Cigna, PO Box 31066, Charlotte, NC 28321-1066, (800)244-6224 439-56 Cigna Healthcare, PO Box 8014, Plainville, CT 06062 441-35 Prudential, PO Box 1400, One Campus Dr, Parsippany, NJ 07054 442-50 Public Employees Healthplan (PEHP), 560 E 200 South, Salt Lake City, UT 84102, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-16 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (800)765-7347 444-10 RMSCO, PO Box 6309, Syracuse, NY 13217-6309, (877)300-7343 444-15 RMSCO, PO Box 678, Liverpool, NY 13088 451-10 Reserve National Insurance, PO Box 26620, Oklahoma City, OK 73126-0620, (800)654-9106 480-00 Time Insurance, PO Box 624, 515 W Michigan Ave, Milwaukee, WI 53201 486-00 Transport Life Insurance, 714 Main St, Fort Worth, TX 76102 488-00 United Healthcare Insurance, PO Box 9516, New Haven, CT 06534-0516 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 488-35 United Health/Railroad/Active Employees, PO Box 30985, Salt Lake City, UT 84130-0122 488-51 Travelers Insurance, PO Box 8026, San Rafael, CA 94901-8026, (877)582-7767 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, (847)615-1300 489-15 Trustmark Dental, PO Box 2942, Clinton, IA 52733 491-00 Union Fidelity Life Insurance, PO Box 10841, Clearwater, TX 33757-8841 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 495-00 Unum Life Insurance, 221 Congress St, Portland, ME 04122 498-00 United American Insurance Company, PO Box 8080, McKinney, TX 75070, (972)529-5085 498-05 United American, PO Box 26400, Oklahoma City, OK 73216 498-10 United Adminstrative Service, PO Box 5057, San Jose, CA 95150 498-40 United Church of Christ, PO Box 197629, Louisville, KY 40259-7629 508-01 United States Life Insurance, PO Box 1581, MSN 2 E, Neptune, NJ 07754-1581, (732)922-7000 508-40 United Medical Resources, PO Box 145804, Cincinnati, OH 45221, (800)436-3100 508-43 United Medical Resources, PO Box 141337, Cincinnati, OH 45250 510-01 Universal Health Service, PO Box 2843, Warminster, PA 18974-2843, (800)847-7718 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 W Walnut, Suite A, Rogers, AR 72756, (800)421-1362 520-05 Western Health, 529 Kansas City St, Suite 200, Rapid City, SD 57701 523-15 Volusia Health Network, 400 N Clyde Morris Blvd, Daytona Beach, FL 32114, (386)258-4822 524-02 World Insurance, PO Box 3160, Omaha, NE 68103, (402)496-8000 528-00 Amalgamated Health, PO Box 1449, New York, NY 10116, (212)539-5105 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 538-40 Avmed Health Plan, PO Box 2939, Gainesville, FL 32602-2939 558-00 General Dynamic Corp, 97 E Howard St, Quincy, MA 02169 562-00 Hartford Insurance, PO Box 1000, Shelton, CT 06484 562-02 Benefit Planners, PO Box 690450, San Antonio, TX 78269-0450, (800)368-3653 562-04 Hartford Insurance, PO Box 11910, Alexandria, VA 22312 564-00 Harvard University, 1350 Massachusetts Ave, Cambridge, MA 02138 568-01 Idealife, PO Box 12546, Pensacola, FL 32591 574-03 Natl Union Fire C/O Crawford and Company, 466 Totten Pond Rd, Waltham, MA 02401 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, (800)426-7234 592-03 State Farm Mutual Health Insurance Inc, PO Box 3070, Newark, OH 43058-3070, (866)855-1212 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, (312)906-8050 600-15 Medical Card System, PO Box 9023547, San Juan, PR 00902-3547 600-60 National Benefit Plans Inc, Vicare, PO Box 1817, Suffolk, VA 23439, (757)923-3400 600-90 Group Health Insurance, PO Box 2832, New York, NY 10116, (800)624-2414 602-00 Wausau Insurance Company, PO Box 8013, Wausau, WI 54402-8013, (877)810-3664 602-01 Wausau Benefits (Georgia Pacific Group), PO Box 8092, Wausau, WI 54402-8092, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-17 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-18 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (715)841-7111 602-02 Wausau Insurance, 115 W Wausau Ave, PO Box 8013, Wausau, WI 54402-8013, (877)559-4244 606-00 MMSI, 4001 41st St NW, Rochester, MN 55901-8901, (877)832-1822 606-02 MVP, 111 Liberty St, PO Box 2207, Schenectady, NY 12301-2207, (800)666-1762 606-04 MVP Select Care Inc, PO Box 1434, Schenectady, NY 12301 606-05 Arizona Foundation, PO Box 2909, Phoenix, AZ 85062, (800)522-1246 606-06 Star Mark, PO Box 2942, Clinton, IA 52733, (800)522-1246 609-02 Mail Handlers Benefit Plan, PO Box 24503, Tucson, AZ 95734, (800)410-7778 609-03 National Association of Letter Carriers Health Plan, 20547 Waverly Ct, Ashburn, VA 22093 609-04 Postmasters Benefit Plan, PO Box 782369, San Antonio, TX 78278 610-00 McKee Foods Corporation (Self-Insured), PO Box 2078, Collegedale, TN 37315, (423)238-7111 610-10 NPPN, PO Box 7047, Middletown, NY 10940, (800)582-8547 610-50 Benefit Plan Management, PO Box 536, Rockland, MA 02370, (781)753-7500 611-02 National Association (Self-Employed), 41 N Summer St, Holyoke, MA 01042 614-00 Teamsters Health Services, 400 Chapel Rd, Local 559 unit 2A, South Windsor, CT 06074, (860)289-3409 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 02129-1304, (617)241-9220 614-04 Mass Laborers Benefit Fund, PO Box 4000, Burlington, MA 01803, (781)272-1000 614-06 Health and Welfare Fund, The London Agency Ltd, 40 Commercial Way, East Providence, RI 02914-004, (800)343-2236 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 and Welfare, 250 Center St, PMB 361, Auburn, ME Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-19 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 04210 614-11 New England Carpenters Health and Welfare, PO Box 7075, Wilmington, MA 01887, (978)694-1000 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, (413)733-0177 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 Health and Welfare, PO Box 4, Lexington, MA 02420-0001, (781)861-1600 614-24 New England Teamsters, PO Box 38, North Andover, MA 01845-0038, (978)682-7407 614-27 Local 317 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 and Welfare Fund, 256 Freeport St, Local 103, Boston, MA 02122, (617)288-5999 614-41 IUOE Local #4 Health and Welfare, 177 Bedford St, PO Box 4, Lexington, MA 02420, (781)861-1600 614-43 New England Laundry Worker Insurance, 697 Broadway, Somerville, MA 02144 614-45 Magna Preferred, 158-11 Harry Vanarsdale, Flushing, NY 11365 614-46 American Postal Workers Union, PO Box 967, Silver Springs, MD 20910 614-52 Teamsters Local 59, 62 S Sixth Street, New Bedford, MA 02740-5907, (800)880-5959 614-54 Carpenters Health and Welfare, 29 Oakland St, Springfield, MA 01101 614-62 Teamesters Health Services Local 404, PO Box 1370, Springield, MA 01101-1370, (413)733-2191 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, (617)367-7360 614-70 Teamsters Local 671 Health Services, 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 and Welfare Fund, 140 Wood Rd, Suite 104, Braintree, MA 02184 614-94 South West Administrators, PO Box 1121, Alhambra, CA 91802-1121 614-97 Sagamore Health Network, PO Box 6051, Indianapolis, IN 46206, (800)552-6550 615-00 University of Mass Supplemental Health Insurance, University Center, Amherst, MA 01003 615-11 UFCW National Health and Welfare, PO Box 751, Englewood, NJ 07631, (888)773-8329 615-12 Painters District Council Local 35, 25 Colgate Rd, Roslindale, MA 02131 615-15 CT and I Colorado Fuel and Iron, 5 Gateway Center Suite 620, 60 Boulevard of the Allies, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-20 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE Pittsburgh, PA 15222 615-24 New England Electrical Worker's Benefits, PO Box 5817, Wallingford, CT 06492-7617, (800)832-6538 615-26 New England Health Care Welfare Fund, 77 Huyshope Ave, Hartford, CT 06106-7001, (860)728-1100 615-41 Lineco (IBEW Local 322), 2000 Springer Dr, Lumbard, IL 60148-6402, (800)323-7268 615-44 UFCW District 5, 108-36 Queens Blvd, Forest Hills, NY 11375 615-49 Teamsters Union Local 20, 435 S Halley Street, Toledo, OH 43609-2398, (419)243-8800 615-52 Sheet Metal Workers National Health Fund, PO Box 1449, Goodlettsville, TN 37070-1449, (800)831-4914 615-66 Laborers Local 1298, PO Box 309, Fulton, NY 13069-0309, (516)489-3644 616-00 AARP, PO Box 740819, Atlanta, GA 30301-3074, (800)523-5800 616-01 AARP, 215 Long Beach Blvd, Long Beach, CA 90801 616-02 AARP Health Care Options, PO Box 985, Westport, CT 06881-0985, (888)687-0977 618-05 HMC, PO Box 488, Farmington, CT 06031 618-20 Health Comp, PO Box 45018, Fresno, CA 93718 619-00 Hospital Benefits Inc, PO Box 162148, Altamonte Springs, FL 32716, (407)862-0311 622-00 Medical Claims Service, One Wall St, Suite 2A, Ravenswood, WV 26164, (304)273-5384 622-15 Medical Claims Service, 100 River Ridge Dr, Norwood, MA 02062 623-00 HCH Admin, PO Box 1986, Peoria, IL 61656-1986, (800)447-3227 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, (800)678-8161 626-00 St Paul Electrical Construction, Medical Reimbursement Plan, 1330 Conway St, St Paul, MN 55106, (651)776-4239 629-00 American Pioneer Life, PO Box 130, Pensacola, FL 32591-0130, (800)999-2224 630-10 J F Molloy and Associates, PO Box 68947, Indianapolis, IN 46268, (800)331-3287 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, (800)225-4423 638-10 Alternative Risk Management, 10200 SW Numbus, Suite G5, Portland, OR 97223 638-17 First Health, PO Box 22410, Tucson, AZ 85734, (800)225-4423 638-18 First Health, PO Box 535920, Pittsburg, PA 15253-0001 638-20 First Health, PO Box 11950, Coraopolis, PA 15108-6929, (800)815-8189 638-24 First Health, PO Box 23550, Tucson, AZ 85734-3550, (800)852-6011 638-25 First Health, PO Box 23070, Tucson, AZ 85734, (800)280-6658 638-27 First Health, PO Box 11127, Tucson, AZ 85734, (800)571-3517 638-33 First Health, PO Box 9500, Coraopolis, PA 15108-0000, (800)345-8994 638-35 First Health, PO Box 11111, Fort Scott, KS 66701, (800)663-8081 638-43 First Health, PO Box 23809, Tucson, AZ 85734 638-45 First Health, PO Box 671128, Houston, TX 77267 638-47 First Health, PO Box 23130, Tucson, AZ 85734-3130, (800)226-8461 638-50 Altus Dental, PO Box 1557, Providence, RI 02901-0000, (877)223-0558 639-02 Highmark Services, PO Box 535078, Pittsburgh, PA 15253-5078 640-00 Harborside Healthcare, PO Box 4925, Lancaster, PA 17604-4925, (800)235-9562 640-50 Allied Adminstrators, PO Box 2500, San Francisco, CA 94126, (415)986-6276 641-10 Performax, PO Box 61505, King of Prussia, PA 19406, (888)554-7629 641-11 Performax, PO Box 1065, Amherst, NY 14226-1065, (800)283-9538 642-20 Stirling and Stirling Inc, 20 Armory Lane, Milford, CT 06460-3361, (800)447-6689 643-00 Med Tac, PO Box 9110, Newton, MA 02460, (617)244-0222 643-10 Medben, PO Box 2090C, Stow, OH 44224, (800)423-3151 645-50 Uniformed Services Family Health, Brighton Marine, PO Box 9203, Waltham, MA 02454-9203, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-21 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (800)818-8589 646-05 Paradigm, PO Box 1268, Tiston, GA 31793-1268 647-20 Geisinger Health Plan, PO Box 8200, Danville, PA 17821-8200, (570)271-6211 650-50 Mashantucket Plan Administrators, PO Box 3620, Mashantucket, CT 06339, (888)779-6872 653-00 American Maritime Officers Medical Plan, PO Box 35, Dania Beach, FL 33004-0035, (800)348-6515 654-00 ASR Corp, 3033 Orchard Vista Dr SE, Grand Rapids, MI 49546-7000, (616)957-1751 656-01 Diversified Administration Corp, PO Box 299, 369 N Main St, Marlborough, CT 06447-0299, (888)322-2524 656-02 Corersource, PO Box 5190, Tampa, FL 33675, (800)221-8490 658-10 Delta USA, PO Box 5402, Lisle, IL 60532-5402, (800)398-7203 659-05 Zenith Administrators, 101 Convention Center Dr, Suite 600, Las Vegas, NV 89109 659-10 United Chambers, PO Box 3209, Covina, CA 91722 660-10 Presbyterian Health Plan, PO Box 27489, Albuquerque, NM 87125-7489, (800)356-2219 661-02 CBA Inc, 3800 NW 12th, Suite A, Lincoln, NE 68521, (888)673-2872 661-05 Comprehensive Benefits Adm, PO Box 2365, 23 Pachen Rd, South Burlington, VT 05407-2365, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-22 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (802)864-8321 669-10 American National Health Insurance, PO Box 1520, Galveston, TX 77553 670-02 S and S Healthcare, PO Box 141097, Cinninnati, OH 45250, (866)266-1110 670-30 First United American Life Insurance Company, PO Box 3125, Syracuse, NY 13220-3125, (315)451-2544 678-00 Choice Plus of Vermont, PO Box 6589, Syracuse, NY 13217, (802)479-9762 678-10 Choice Benefits, PO Box 10048, Fort Smith, AR 72917-0048, (479)785-6178 680-00 Select Benefit Administrators of America, PO Box 440, Ashland, WI 54806-0440, (800)497-3699 680-50 Starmark, PO Box 420, Freeport, IL 61032, (800)371-1633 681-01 National Benefits Administrators Inc, PO Box 263, Parsippany, NJ 07054-0263, (800)258-0103 682-50 American Trust Administrators, PO Box 87, Shawnee Mission, KS 66201, (913)451-4900 687-00 Employee Benefit Plan Administration (EPBA), PO Box 2000, Exeter, NH 03833-2000, (800)578-3272 687-02 Employee Benefit Administrators Inc, 64 Schoosett St, Rte 139, Pembroke, MA 02359, (781)826-1177 687-03 Employee Benefit Managment Services (EBMS), PO Box 4000, Draper, UT 84020, (801)572-0720 687-06 Employee Benefit Mgmt Service (EBMS), PO Box 21367, Billings, MT 59104, (406)245-3575 687-20 Employee Benefits Corp, 1200 E Glen Avenue, Peoria Heights, IL 61616-5348, (309)679-0810 688-45 Assoc Administrative Inc, PO Box 6680, Portland, OR 97228 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, (877)823-6334 691-00 US Administrators, PO Box 30654, Los Angeles, CA 90030 691-35 Planned Administrators, PO Box 6702, Columbia, SC 29260-0000 692-01 Hallmark Health Advantage, 100 Hospital Rd, Malden, MA 02148 693-01 P5 Eletronic Health Services, PO Box 9554, Salt Lake City, UT 84109-0554 693-50 Medica, Route 2901, PO Box 659752, San Antonio, TX 78265-9752, (800)952-3455 694-03 Willis of Kansas, Koch Industries Employees, PO Box 2906, Wichita, KS 67201, (800)235-7160 696-00 Group Health Incoporated, PO Box 3000, New York, NY 10116 696-30 Group Resources Inc, PO Box 100043, Duluth, GA 30096-9343, (770)242-7776 698-00 Corporate Benefits Services, Armstrong Claims Division, 139 S Tryon St 6th Fl, Charlotte, NC Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-23 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 28202, (704)373-0447 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 1268, Tifton, GA 31793-1268, (229)386-1751 700-11 Protective Dental Care, PO Box 830626, Birmingham, AL 35283-0626, (800)866-5020 700-15 Complete Care Control Simplex, Simplex Plaza, Gardner, MA 01441 700-37 Montachussett Health Plan, 285 Central St, Leominster Plaza, Leominster, MA 01453 700-48 US Now, 8350 N Central Expressway, Suite 650A, Dallas, TX 75206 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, (800)996-8401 700-77 Legett and Platt Company, PO Box 757, Carthage, MO 64836, (417)358-8131 700-81 Group Insurance Service Center, PO Box 9120, Marshfield, MA 02050-9120, (800)242-3834 700-90 Health Plan Nevada (HPN), PO Box 15645, Las Vegas, NV 89114, (702)242-7300 701-02 Machigonne Benefit Administrators, PO Box 3859, Portland, ME 04104, (800)245-3529 701-10 Benefits Management Services, PO Box 1178, Matthews, NC 28106 701-25 Life Wise Health Plan, PO Box 7709, Bend, OR 97708-7709 701-40 APA Partners Inc, 8 British American Blvd, PO Box 1506, Latham, NY 12110-8006, (800)833-3650 701-80 Ironclad, 161 Granite Ave, Dorchester, MA 02124-5491, (617)436-3500 702-25 CBCA Administrators, PO Box 1539, Fort Worth, TX 76101-1539, (800)808-4515 702-30 CBC Administrators, PO Box 776, Melville, NY 11747, (877)769-3942 702-35 USI Administrators, PO Box 8911, Melville, NY 11747-8911, (877)769-3942 702-40 CBCA, PO Box 5190, Tampa, FL 33675 702-41 CBCA, PO Box 9888, Savannah, GA 31412 702-42 CBCA, PO Box 9000, London, KY 40742 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, (800)274-6965 703-30 Coresource, Inc, 4940 Campbell Blvd, Suite 200, Baltimore, MD 21236, (410)931-5060 703-40 Coresource, PO Box 168, 4801 Southwick Dr, Matteson, IL 60443-0168, (800)848-3012 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 2920, Clinton, IA 52733, (800)223-3943 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 708-05 Team Health, PO Box 612768, Dallas, TX 75261, (800)275-1171 709-00 Jefferson-Pilot Life Insurance, PO Box 20727, Greensboro, NC 27420 709-03 Shanta Administrative Services, PO Box 1747, Redmond, OR 97708-4001, (800)441-4518 711-00 Excellus Benefit Services, PO Box 13321, Syracuse, NY 13221, (315)448-6925 711-01 FCE Benefit Administrators Inc, Claims Clearing Account, 1010 Foster City Blvd, Foster City, CA Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-24 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 94404, (800)899-9355 712-04 GE Group Administrators, PO Box 3005, Agawam, MA 01001, (888)255-8961 712-05 General Electric Health Care Preferred, PO Box 740801, Atlanta, GA 30374-0801, (800)432-3450 712-06 General Electric Capital Insurance, 1650 Los Gamos Dr, San Rafael, CA 94903 712-07 General Electric Capital Assurance Company, File #56790, Los Angeles, CA 90074-6790 712-10 Ge Group Administrators, PO Box 100252, Columbia, SC 29202-3252 714-20 Claims Management Service, PO Box 10888, Green Bay, WI 54307 714-25 Claim Management Services, PO Box 279, West Bend, WI 53095 715-25 USSA Life Insurance Company, 9800 Frederick Rd, San Antonio, TX 78288-0346, (800)531-8000 717-00 Fra Milicare, PO Box 10340, Des Moines, IA 50306-0340, (800)424-1120 720-10 Sisco, PO Box 389, Dubuque, IA 52004 720-20 Q3 Business Tech Corp for Votaw Electric, PO Box 15952, Fort Wayne, IN 46885-5952, (219)492-9979 722-00 Northeast Delta, 6 London St, Concord, NH 03301 730-50 Babb Inc, 850 Ridge Ave Ste 1, Pittsburgh, PA 15212-6095, (800)245-6102 733-00 American Travellers Life Insurance, 3220 Tillman Dr, Bensalem, PA 19020, (800)441-3978 734-01 Definity Health, PO Box 9525, Amherst, NY 14226-9525, (866)333-4648 737-01 Corporate Benefits Service Inc, PO Box 12954, Charlotte, NC 28220-2954, (704)373-0447 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 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 747-05 Susquehanna Administrators, 1 Executive Park Dr, Suite 300, Bedford, NH 03102 749-60 Big Lots Associates 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 753-02 United Administrative Services, PO Box 5057, San Jose, CA 95150-5057, (408)286-7663 756-00 Principal Financial Group, PO Box 39710, Colorado Spgs, CO 80949-3910, (800)422-5002 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, (800)447-4701 756-13 Principal Financial Group, 1245 Corporate Blvd, Suite 200, Aurora, IL 60504 756-15 Principal Life Insurance, PO Box 39710, Colorado Springs, CO 80949-3910, (800)247-4695 756-50 Private Healthcare System, PHCS/3M, PO Box 5066, Des Plaines, IL 60017-5066, (800)292-9902 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, (631)420-4100 758-00 Hillcrest Community Health Plan, 1201 Troy Rd, Latham, NY 12110 762-10 Kaiser Permanete, PO Box 190849, Atlanta, GA 31119 762-15 Kaiser Permanente, PO Box 373150, Denver, CO 80237, (800)382-4661 767-00 Ultra Benefits Inc, PO Box 763, Westboro, MA 01581, (866)858-7223 774-30 Willis Corroon Insurance, PO Box 2697, Wichita, KS 67201, (800)235-7160 776-00 Samba, 11301 Old Georgetown Rd, Rockville, MD 20852 800-00 Masters Mates and Pilots Health and Benefit Plan, 5700 Hammonds Ferry Rd, Linthicum Heights, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-25 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE MD 21090-1996, (410)850-8500 803-03 Administrators and Consultants, PO Box 4925, Lancaster, PA 17604-4925, (717)299-0371 803-20 Administrative Enterprises Inc, 3404 W Cheryl Dr, Suite 281, Phoenix, AZ 85051 805-50 Watkins Assoc Industries, PO Box 1738, Atlanta, GA 30101-1738, (800)333-3841 810-00 Vanguard Group Inc, 1979 Marcus Ave, Lake Success, NY 11042, (516)616-6011 810-12 New World Claims Service, 2624 N 5th St, Niles, MI 9120, (781)762-5511 811-00 American Express, 1650 Los Gamos Dr, San Rafael, CA 94903-1899 813-00 Berkshire Health Plan, 279 Dalton Ave, Pittsfield, MA 01201 814-03 Health & Welfare Local 42, Tyrrell Consultants, PO Box 64, Lexington, MA 02173 814-41 Connecticut Carpenters Fund, 10 Broadway, Hamden, CT 06518-2699 814-56 Laborers National, PO Box 1100, Columbia, MD 20144 816-01 Mediplan, 502 Valley Rd, Wayne, NJ 07410, (973)696-3111 816-05 Mennonite Mutual Aid Associates, PO Box 483, Goshen, IN 46527, (574)533-9511 828-05 Southern Health Services, PO Box 7704, London, KY 40742, (800)627-4872 830-00 Administrative Service Consultants, 3301 E Royalton Rd, Cleveland, OH 44147, (419)423-3823 830-08 Employee Benefit Consultants Inc, PO Box 928, Findlay, OH 45830-0928, (419)423-3823 832-00 American Baptist Churches Medical Plan, 475 Riverside Dr, Rm 1700, New York, NY 10115 832-40 Interactive Corp, PO Box 567, Farmington, CT 06034 833-00 Philadelphia America Life, 100 N 6th St Suite 800, Waco, TX 76701 836-40 POMCO, PO Box 6329, Syracuse, NY 13217 839-04 Goodyear Medical Benefit Plan, PO Box 677, Akron, OH 44309 839-05 One Nation Benefit Administration, PO Box 1268, Columbus, OH 43216 840-20 Alicare, PO Box 1435, New York, NY 10116 840-50 Longview Fibre Company, 1220 SW Morrison, Suite 300, Portland, OR 97205, (503)224-0048 840-80 Alicare Inc, PO Box 1442, New York, NY 10116, (212)539-5000 843-35 Mega Life Dental, PO Box 952009, N Richland Hills, TX 76182 843-40 Mega Life and Health Insurance, PO Box 982009, North Richland Hills, TX 76182-8009, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-26 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (800)527-2845 843-45 Mega Life Student Insurance, PO Box 809025, Dallas, TX 75380-9025, (800)767-0700 844-01 Benesight, PO Box 29050, Phoenix, AZ 85072 844-21 Benesight, PO Box 375, Pueblo, CO 81002-0375, (800)992-8354 844-22 Benesight/Dental, PO Box 360, Pueblo, CO 81002-0360, (800)345-8563 844-30 The TPA Inc, PO Box 7045, Rockford, IL 61125-7045, (800)842-5749 844-40 Benesight, PO Box 370, Pueblo, CO 81002-0370, (800)992-8354 854-00 Health Choice, 164 High St, Greenfield, MA 01301 863-02 Harrington Benefit Service Inc., PO Box 730, Pueblo, CO 81002-0720, (800)446-8182 872-10 Advanced Benefit Resources, PO Box 350, Woodbury, NY 11797-0350 872-20 Advanced Administration, 101 N Lake Destiny Rd, Suite 130, Maitland, FL 32751, (800)785-4544 876-20 Harrington Benefit Services Inc, PO Box 1394, Duncan, OK 73534-1394, (800)527-4296 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, (800)233-4013 886-05 Humana Claims, PO Box 14610, Lexington, KY 40512-4610, (800)558-4444 891-37 NCAS, PO Box 10104, Fairfax, VA 22030, (866)662-4084 891-38 NCAS/National Claims Administrative Service, 7083 Grand National Drive Suite, Orlando, FL Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-27 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 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, (978)825-7085 895-01 Star Administrative Services, PO Box 55270, Phoenix, AZ 85078, (800)308-5948 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 and 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, (800)748-0003 898-30 Group Administrators, Ltd, 1880 N Roselle Rd, Suite 214, Schaumburg, IL 60195 898-50 Group Benefits Services, 6 N Park Dr, Suite 310, Hunt Valley, MD 21091, (800)337-4973 899-03 Pacificare, PO Box 6099, Cypress, CA 90630, (866)316-9776 900-03 Dow Chemical, Group Insurance Dept., PO Box 1701, Midland, MI 48640, (989)636-1000 900-05 Fedex Freight East, PO Box 5007, Harrison, AR 72602-00 900-10 Fedex Freight East, 419 East Main St, Middletown, NY 10940 900-23 Vetri System, PO Box 5028, Troy, MI 48007 900-32 United Benefits, PO Box 2480, Daytona Beach, FL 32115-2480, (800)323-4890 900-69 John Riley Insurance, PO Box 356, West Boylston, MA 01583 900-89 HRM Claim Management, Upjohn Claims, PO Box 4089, Kalamazoo, MI 49003 900-91 Benefit Concepts, PO Box 60608, King of Prussia, PA 19406-0608, (610)337-2600 900-94 Benefit Planners Inc, PO Box 690450, San Antonio, TX 78269 901-20 Chesterfield Resource, PO Box 1884, Akron, OH 44309, (800)321-0935 901-26 Atlantic Administrators, 135 Beaver St, Waltham, MA 02452 901-31 Atlantic Administrators Inc, PO Box 637, North Andover, MA 01845 901-41 Health New England, One Monarch Place, Claims Dept, Springfield, MA 01144-1500, (413)787-4000 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, (800)222-2184 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 903-58 MassHealth/MCO BMC HealthNet Plan, PO Box 55282, Boston, MA 02205-5282 905-28 Rewards Administration Center, PO Box 29005, Phoenix, AZ 85038-9005, (800)421-3973 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 and Insurance Office, 1220 S W Morrison St, Suite 300, Portland, OR 97205, Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-28 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE (800)547-4457 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, (810)779-7676 906-45 Colonial Benefit Insurance Administration, PO Box 3770, 8540 Ashwood Dr, Capital Heights, MD 20743 906-47 Deseret Mutual Health Care, PO Box 45530, Salt Lake City, UT 84145 906-49 Strategic Resource Company (SRC), PO Box 23759, Columbia, SC 29224-3759, (800)869-0808 906-54 Preferred Care, 259 Monroe Ave, Rochester, NY 14607-3636, (585)325-3114 906-70 Group Dental Benefits, PO Box 1477, Greenfield, MA 01302-1477, (800)451-2513 906-87 Automated Benefit Services, PO Box 37506, Oak Park, MI 48237-0506, (586)826-4410 906-89 Inter-Care, PO Box 3559, Englewood, CO 80155 908-44 Managed Benefit Plan, PO Box 744, Hackettstown, NJ 07840 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, (630)773-3800 908-67 Gallagher Benefit Services, Department 5010, PO Box 162721, Austin, TX 78716 908-75 Galyan's Trading Co. Health Benefits, PO Box 39710, Colorado Springs, CO 80949-3910, (317)612-2439 910-10 Neighborhood Health Plan, 253 Summer St, Boston, MA 02210, (800)433-5556 910-30 Pan American Life Insurance, PO Box 61070, New Orleans, LA 70610 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 School Street, Lynn, MA 01901-2952, (781)581-7565 913-05 ESP of Mutual Healthcare, 1140 Dorchester Ave, Dorchester, MA 02125 913-06 ESP Harbor Health Services, 2216 Dorchester Ave, Dorchester, MA 02124 913-20 Benefit Coordinators Corporation, 111 Ryan Court, Suite 300, Pittsburgh, PA 15205 914-00 Hospice Program. Bill hospice provider, if service is related. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-29 ALL PROVIDER MANUALS ALL-131 TRANSMITTAL LETTER 07/01/05 DATE 920-00 Self-Reported Insurance. Ask for copy of card.920-10 Medco Health Solutions Inc, Pharmacy Services Dept, 399 Jefferson Rd Stop P-15, Parsippany, NJ 07054 920-15 Eckherd, PO Box 2860, Pittsburgh, PA 15238 920-20 Express Scripts, PO Box 66773, St Louis, MO 63166, (800)206-4005 920-25 Caremark, PO Box 686005, San Antonio, TX 78268 920-30 Advanced PCS, PO Box 52116, Phoenix, AZ 58072 920-35 Wellpoint, PO Box 4165, Woodland Hills, CA 91365 920-40 Aetna Pharmacy, PO Box 398106, Minneapolis, MN 55439 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 SUBCHAPTER NUMBER AND TITLE APPENDIX C: THIRD-PARTY-LIABILITY CODES PAGE C-30 ALL PROVIDER MANUALS TRANSMITTAL LETTER ALL-131 DATE 07/01/05 This page is reserved.