Payer ID provider number reference — Facility

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Rev. April 20231Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company independent licensees of the Blue Cross and Blue Shield ID provider number reference FacilityUse this guide as a reference tool when submitting Facility claims. The information was current at the time of publication. We will announce changes on the provider News Center and the provider Engagement, Analytics & Reparting (PEAR) portal. PrefixProduct namePayer information for electronic claimsPaper claim mailing addressBilling providerISA-08GS-03Keystone Health Plan EastIndependenceQCGKeystone Health Plan East POS5470495056Claims Receipt Box 211184Eagan, MN 55121Valid and registered NPI is (837I)Loop 2010AANM108 = XXNM109 = NPI #Paper (UB-04)NPI # Box 56QCHKeystone Health Plan East HMOQCIKeystone 65 HMOKeystone 65 Focus Rx HMOQCJKeystone Health Plan East ERISA POSQCKKeystone 65 POSQCLKeystone Health Plan East ERISA HMOQHXIBC HMO Proactive Individual Off ExchangeQSPIBC HMO Proactive Small GroupQXJI

Payer ID provider number reference — Facility Rev. January 2022 2 Payer information Prefix Product name for electronic claims Emdeon payer information* Paper claim mailing address Billing provider ISA-08 GS-03 Personal Choice® (continued) Independence Valid and registered NPIReserve, is required. Electronic (837I) Loop 2010AA NM108 = XX

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