Payer ID provider number reference — Facility

1 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)

2 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 Small GroupQXJIBC HMO Proactive Individual On ExchangeYXQK eystone HMO Platinum On Exchange*Keystone HMO Gold On ExchangeKeystone HMO Silver Classic On ExchangeKeystone HMO Silver Basic On ExchangeKeystone HMO Bronze On ExchangeKeystone HMO Gold Classic On ExchangeYXRS mall Group POS On Exchange*YXWK eystone HMO Platinum Off Exchange*Keystone HMO Gold Off ExchangeKeystone HMO Silver Classic Off ExchangeKeystone HMO Bronze Off ExchangePersonal Choice IndependenceWYXP ersonal Choice EPO HSA5470454704 Claims Receipt Box 211184 Eagan, MN 55121 YXFP ersonal Choice PPOYXKP ersonal Choice 65SM PPO Personal Choice 65 Prime Rx PPORev.

3 April 20232 PrefixProduct namePayer information for electronic claimsPaper claim mailing addressBilling providerISA-08GS-03 Personal Choice (continued)IndependenceValid and registered NPI is (837I)Loop 2010 AANM108 = XXNM109 = NPI #Paper (UB-04)NPI # Box 56 YXOP ersonal Choice PPO Platinum Off Exchange*5470454704 Claims Receipt Box 211184 Eagan, MN 55121 Personal Choice PPO Gold Off ExchangePersonal Choice PPO Silver Off ExchangePersonal Choice PPO Bronze Off Exchange Personal Choice PPO Bronze Reserve Off Exchange*YXPP ersonal Choice PPO Platinum On Exchange*Personal Choice PPO Gold On ExchangePersonal Choice PPO Gold Classic On ExchangePersonal Choice PPO Silver On ExchangePersonal Choice PPO Bronze On Exchange Personal Choice PPO Bronze Reserve On Exchange*YXUS mall Group PPO On Exchange*YXXP ersonal Choice EPO Catastrophic, Bronze Basic, Gold*, Bronze Reserve, Platinum*.

4 And Silver Reserve* On ExchangeYXYP ersonal Choice EPO Catastrophic, Bronze Basic, Gold*, Bronze Reserve, Platinum*, Silver Reserve*, and Silver Reserve Select* Off ExchangeBlueCard IndependenceAll National PPO PrefixesPPO Blue Cross or Blue Shield member ID card with PPO in a suitcase and a prefix not defined previously Medicare Advantage PPO Blue Cross or Blue Shield member ID card with MA PPO in a suitcase and a prefix not defined previously 5470454704 Claims Receipt Box 211184 Eagan, MN 55121 Payer ID provider number reference FacilityRev. April 20233 PrefixProduct namePayer information for electronic claimsPaper claim mailing addressBilling providerISA-08GS-03 BlueHPN IndependenceAll BlueHPN PrefixesID Card Front: BlueHPN members will be identified by the Blue High Performance Network name and the BlueHPN in a suitcase logo ID Card Back.

5 A disclaimer indicates that the member has limited benefits outside of BlueHPN product areas Prefixes will be added to this grid, as Receipt Box 211184 Eagan, MN 55121 Valid and registered NPI is (837I)Loop 2010 AANM108 = XXNM109 = NPI #Paper (UB-04)NPI # Box 56 Blue Cross IndependenceQCAT raditional Blue Cross Blue Shield 5470454704 Claims Receipt Box 211184 Eagan, MN 55121 QCCC oncurrent Major MedicalQCES ecurity 65 , 65 Special, and MedigapSecurityQCNC omprehensive Major Medical (CMM)QCOBlue Cross IndemnityQCRM edigap, Blue Cross onlyQMOM edigapFreedomPayer ID provider number reference FacilityPayer ID provider number reference FacilityRev. April 20234* This product is no longer offered. Providers outside of our five-county service area (Bucks, Chester, Delaware, Montgomery, and Philadelphia counties) as well as out-of-state providers should submit BlueCard-related claims to their local plan, with the exception of providers who are contracted with Independence for the member s plan or who meet the conditions of the Ancillary Claim Filing rules.

6 When treating non-Independence members, facilities contracted with other local area Blue Cross and/or Blue Shield (BCBS) health plans ( , Capital Blue Cross, Horizon Blue Cross Blue Shield of New Jersey, and Highmark BCBS Delaware) must submit claims to the contracted BCBS health plan for the member based on their member ID namePayer information for electronic claimsPaper claim mailing addressBilling providerISA-08GS-03 Federal Blue CrossIndependenceValid and registered NPI is (837I)Loop 2010 AANM108 = XXNM109 = NPI #Paper (UB-04)NPI # Box 56R followed by 8 numeric charactersFederal Employee Program (FEP) member ID starts with an R 5470454704 Claims Receipt Box 211184 Eagan, MN 55121 Third-party administratorsIndependence AdministratorsIndependence Administrators National PPO prefixesIndependence Administrators logo on the ID card with PPO in a suitcase and a prefix not defined previouslyIndependence AdministratorsFor additional claims information, visit Administratorsc/o Processing Box 21974 Eagan, MN 55121 Independence Administrators BlueHPN prefixesID Card Front: BlueHPN members will be identified by the Blue High Performance Network name and the BlueHPN in a suitcase logoID Card Back.

7 A disclaimer indicates that the member has limited benefits outside of BlueHPN product areasPrefixes will be added to this grid, as AdministratorsFor additional claims information, visit Administrators c/o Processing Box 21974 Eagan, MN 55121