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Payer ID provider number reference — Facility

Rev. April 20231 Independence 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-03 Keystone Health Plan EastIndependenceQCGK eystone Health Plan East POS5470495056 Claims Receipt Box 211184 Eagan, MN 55121 Valid and registered NPI is (837I)Loop 2010 AANM108 = XXNM109 = NPI #Paper (UB-04)NPI # Box 56 QCHK eystone Health Plan East HMOQCIK eystone 65 HMOK eystone 65 Focus Rx HMOQCJK eystone Health Plan East ERISA POSQCKK eystone 65 POSQCLK eystone Health Plan East ERISA HMOQHXIBC HMO Proactive Individual Off ExchangeQSPIBC HMO Proactive S

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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