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South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYEffective 01/01/19CARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENT7541199 SEIU NATIONAL BENEFIT FUNDPO BOX 1007NEW YORKNY1010810074621ST MEDICAL NETWORKPO BOX 724317ATLANTAGA311398889806676 CODE ASSIGNED BY SCHA71021ST CENTURY HEALTH AND BENEFITS, INC.PO BOX 5037CHERRY HILLNJ080348003234890F273PADMINISTRATORSPO BOX 247ONALASKAWI546506087793000 DENTAL ONLYB14A.C.S. CONSULTING SERVICES, INC.PO BOX 03367592013Appendix 2-1
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEB14DN A.C.S. CONSULTING SERVICES, INC.ADDRESS LINECITYSTZIPPO BOX 2000WINSTON-SALEMNC271022000PHONE NUM CARRIER COMMENT3367592013 DENTAL ONLY650ABBEVILLE COUNTY543ACHA/CAREINGTON INTERNATIONAL CORPPO BOX 2568FRISCOTX750348002900523 CODE ASSIGNED BY SCHA266ACMG ADMINISTRATORS OF SOUTH CAROLINA2570 TECHNICAL DR.MIAMISBURGOH453428002326242786ACS BENEFIT SERVICES, INC.PO BOX 2000WINSTON-SALEMNC271022000C49ACS CONSULTING SERVICES, INC.PO BOX 2000WINSTON-SALEMNC271028008495370 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA8008495370 WAS PENN WESTERN355ACTIVA HEALTH GROUPPHOENIXAZ850186024689500341ADMINISTRATIV E CONCEPTS, INC.WAYNEPA190878882939229563ADMINISTRATIV E SERVICE CONSULTANTS4350 E. CAMELBACK RD. #200994 OLD EAGLE SCHOOLRD., STE. 10053301 E ROYALTON RD.BLDG. DBROADVIEW HEIGHTSOH44147346ADMINISTRATIV E SERVICES, INC.2187 NORTHLAKEPARKWAY STE. 106 BLDG#9TUCKERGA300847709343953829ADMINISTRATIV E SOLUTIONSPO BOX 2490ALPHARETTAGA300236783390211731ADOVA HEALTHPO BOX 725549ATLANTAGA311398664704959 CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHAC15ADVANCE PCSPO BOX 52188PHOENIXAZ850722196D11ADVANCED BENEFIT SOLUTIONSPO BOX 71490PHOENIXAZ850508884191094 CODE NOT REQUESTED BYMEDICAID ASSIGNED BY SCHAMEDICARE SUPPLEMENTALPLAN310ADVANCED DATA SOLUTIONSPO BOX 723097ATLANTAGA311398007425246C72ADVANCED INSURANCE ADMINISTRATION125 MERRILL DR., STE. 2000 LITTLE ROCKAR722118882424800 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHAD33ADVANTRA FREEDOMPO BOX 7154LONDONKY407427154C88ADVENTIST RISK MANAGEMENTPO BOX 1928GRAPEVINETX760998006380589899AETNA HEALTH PLANS OF THE CAROLINAS, INC.3 CENTERVIEW DR.GREENSBORONC274078004591466 HMO PLAN ONLYA55AETNA LIFE AND CASUALTYPO BOX 36890LOUISVILLEKY402328004233289 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHAD16AETNA MEDICARE OPEN PLANPO BOX 14079LEXINGTONKY4051240794803914600 SEE CARRIER 4718007135095 MEDICARE ADVANTAGE PLAN8006240756 MEDICARE ADVANTAGE PLANAppendix 2-2
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENT100RXAETNA PHARMACYPO BOX 52444PHOENIXAZ8507224448002386279100AETNA US HEALTHCAREPO BOX 14079LEXINGTONKY405128003334432100DNAETNA US HEALTHCAREPO BOX 14094LEXINGTONKY405128004517715B43AFFINITY HEALTH PLANPO BOX 981726EL PASOTX79998172686624756787761 S. LIMESTONE ST., STE.3011932 WYNNTON RD.SPRINGFIELDOH45502595AFID (ASSO. OF FRANCHISE AND INDEPENDENTDIST.)AFLAC -AMERICAN FAMILY LIFE ASSO COCOLUMBUSGA31999289AFTRA HEALTH FUND261 MADISON AVE.NEW YORKNY10016E55AG ADMINISTRATORSPO BOX 979VALLEY FORGEPA19482651AIKEN COUNTY455ALASKA TEAMSTER TRUST520 E 34TH AVE., STE. 107ANCHORAGEAK9950341168004784450 CODE ASSIGNED BY SCHA344ALIA CLAIMS DEPARTMENTPO BOX 9060PHOENIXAZ8506890608008825707 CODE NOT REQUESTED BYMEDICAID. SCHA ASSIGNED299ALICAREPO BOX 1447NEW YORKNY101162125395115200ALL AMERICAN LIFE INSURANCE CO.8501 WEST HIGGINS RD.CHICAGOIL606317733996645199ALL OTHER CARRIERSF54ALLEGIANCEPO BOX 3018MISSOULAMT598068559992271 ADDED BY SC REVENUE ANDFISCAL AFFAIRSE54ALLEGIANCE BENEFIT PLAN MANAGEMENTPO BOX 3018MISSOULAMT5980630188008771122560ALLEN MEDICAL CLAIMS ADMINISTRATORSPO BOX 978FT. VALLEYGA3103009788008255406652ALLENDALE COUNTY272ALLIANCE HEALTH BENEFIT PLANPO BOX 6443ROCKVILLEMD208508003423289521ALLIANCE PPO, INC.PO BOX 934FREDERICKMD217058002350123 CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHAA33ALLIANT HEALTH PLANS, INC.PO BOX 21109ROANOKEVA241088002834927413ALLIED BENEFITS SYSTEMPO BOX 909786-60690CHICAGOIL6069097868002882078135ALLIED NATIONAL, INC.PO BOX 419233KANSAS CITYMO6414162338008257531 CARRIER WAS ALLIED GROUPINSURANCE TRUST115ALLSTATE INSURANCEPO BOX 7068COLUMBIASC292028667669016 CODE IN OPEN STATUS BYSCHA80099235228005624690 CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA80063486288003668997 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHAAppendix 2-3
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENT193ALLSTATE WORKPLACE DIVISIONPO BOX 853916RICHARDSONTX7508539168009377039581ALTA RXPO BOX 30081SALT LAKE CITYUT841308009985033A02ALTERNATIVE BENEFITS PLANS, INC.2920 BRANDYWINE RD.,STE. 106ATLANTAGA303418002417319E44ALTERNATIVE INSURANCE RESOURCE, INC.PO BOX E RISK MANAGEMENTS (ARM LTD)814 N.W. HIGHWAYARLINGTON HEIGHTSIL600048003921770234ALWAYSCARE BENEFITS, INC.PO BOX 80139BATON ROUGELA708988887295433 DENTAL PLAN161AMA INSURANCE AGENCY, INC.PO BOX 804238CHICAGOIL606808004585736 CODE NOT REQUESTED BYMEDICAID. SCHA ASSIGNED297AMALGAMATED LIFE INSURANCEPO BOX 1451NEW YORKNY1011614512124735700F57AMBETTER PEACH STATE HEALTH PLANPO BOX 5010FARMINGTONMD6364050108776871180 ADDED BY SC REVENUE ANDFISCAL AFFAIRSC07AMERIBEN SOLUTIONSPO BOX 7186BOISEID83707309AMERICAN ADMINISTRATIVE GROUPPO BOX 5227LISLEIL6053252276304939252 CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA910AMERICAN ADMINISTRATIVE GROUPPO BOX 5227LISLEIL6053252278003545112 WAS GALLAGER & BASSETTSERVICES469AMERICAN ASSOCIATION OF RETIRED PERSONS(AARP)PO BOX 740819ATLANTAGA303748005235880B61AMERICAN BEHAVIORAL3680 GRANDVIEWPARKWAY STE. 100BIRMINGHAMAL352438009258327968AMERICAN BENEFIT ADMINISTRATIVE SERVICESPO BOX 0928BROOKFIELDWI530086304161111271AMERICAN BENEFIT PLAN ADMINISTRATOR22OO-B ROSSELLE ST.JACKSONVILLEFL322048004685126488AMERICAN BENEFITS MANAGEMENT8310 PORT JACKSON AVE.NORTHWESTNORTH CANTONOH447203309665500B44AMERICAN CHOICE HEALTH PLAN, LLCPO BOX 922043HOUSTONTX772928006334226B44DN AMERICAN CHOICE HEALTH PLAN, LLCPO BOX 922009HOUSTONTX772928005989799A93AMERICAN COLLEGE OF SURGEONSPO BOX 2522FORT WORTHTX761132522778AMERICAN CONTINENTAL INSURANCE COPO BOX 14770LEXINGTONKY405128004331672 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA8002644000D48AMERICAN CONTINENTAL INSURANCE COPO BOX 2368BRENTWOODTN370246153371300 MEDICARE ADVANTAGE PLAN8007867930Appendix 2-4
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENT106AMERICAN FIDELITY ASSURANCE BENEFITSPO BOX 25160OKLAHOMA CITYOK7312501608006548489150AMERICAN GENERAL LIFE AND ACCIDENT INS COPO BOX 1500NASHVILLETN3720215008008882452951AMERICAN GROUP ADMINISTRATORS101 CONVENTION CENTERDR., STE. 200LAS VEGASNE891098008424742A57AMERICAN GROUP ADMINISTRATORS, INC.101 CONVENTION CENTERDR., STE. 200LAS VEGASNV891098008424742 CODE ASSIGNED BY SCHA118AMERICAN HEALTH & LIFE INSURANCE300 ST. PAUL PLACEBALTIMOREMD212023013323000C92AMERICAN HEALTH CARE3850 ATHERTON RD.ROCKLINCA957658008728276C92DN AMERICAN HEALTH CARE3001 DOUGLAS ST.ROSEVILLECA956618008728276919AMERICAN HEALTH GROUP, INC.PO BOX 1500MAUMEEOH435378008728276383AMERICAN HEALTHCARE ALLIANCEPO BOX 8530KANSAS CITYMO6411405308772840102119AMERICAN HERITAGE LIFE INSURANCE1776 AMERICAN HERITAGELIFE DR.JACKSONVILLEFL322248005358086840AMERICAN, INCOME LIFE INSURANCE COMPANYPO BOX 2608WACOTX767978177723050B69AMERICAN INSURANCE ADMINISTRATORSPO BOX 2348COLUMBUSOH4321623488009221245 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA.D38AMERICAN INSURANCE ADMINISTRATORSPO BOX 2348COLUMBUSOH432168009221245 CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA369AMERICAN INTERNATIONAL GROUPPO BOX 25050WILMINGTONDE198998004687077167AMERICAN INTERNATIONAL GROUP (AIG) ACCIDENTPO BOX 26050OVERLAND PARKKS662258887221668A62AMERICAN MEDICAL AND LIFE INSURANCE (AMLI)PO BOX 1353CHICAGOIL606908882641512532AMERICAN MEDICAL SECURITYPO BOX 19032GREEN BAYWI5430790328002325432120AMERICAN NATIONAL INSURANCE COMPANYPO BOX 1790GALVESTONTX775538008996803B98AMERICAN PIONEER LIFE INSURANCE COMPANYPO BOX 130PENSACOLAFL325918005381053321AMERICAN POSTAL WORKERS UNION HEALTH PLAN PO BOX 188004CHATTANOOGATN374228002222798321DNAMERICAN POSTAL WORKERS UNION HEALTH PLAN PO BOX 1358GLEN BURNIEMD210608002222798164AMERICAN PROGRESSIVE INSURANCEPO BOX 130PENSACOLAFL3259101308006268913A05AMERICAN PUBLIC LIFE INSURANCE CO.PO BOX 925JACKSONMS392058002568606722AMERICAN REPUBLIC INSURANCE COMPANYPO BOX 21670EAGANMN551218002472190C70AMERICAN RETIREMENT LIFEPO BOX 30010AUSTINTX7575530108664591755 REQUESTED BY THE SCHAAppendix 2-5
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENT875AMERICAN SENTINELPO BOX 61140HARRISBURGPA171061140503AMERICAN SPECIAL RISK MANAGEMENT509 SOUTH LENOLA RD.,BLDG. TWOMOORESTOWNNJ080578003597475C82AMERICAN STANDARD LIFE & ACCIDENT INS. CO.PO DRAWER 3248, 224NORTH INDEPENDENTENIDOK737014052334000 CODE IN OPEN STATUS BYSCHA253AMERICAN STERLING INSURANCE SERVICESPO BOX 26103OVERLAND PARKKS662258772926037125AMERICAN TRAVELERS LIFE INSURANCE COMPANY3220 TILLMAN DR.BEN SALEMPA190202152441600275AMERICAN TRUST ADMINISTRATORSPO BOX 87SHAWNEE MISSIONKS662019134514900496AMERICAN VETERINARIAN MEDICINE ASSN.PO BOX 909720CHICAGOIL6060497208006216360D61AMERICA'S 1ST CHOICEPO BOX 210769COLUMBIASC292108663213947 MEDICARE ADVANTAGE PLAND23AMERICA'S HEALTH CHOICE MEDICAL PLANS,(HMO)762 SOUTH US HWY. ONEPMB 224VERO BEACHFL329628003089823 MEDICARE ADVANTAGE PLAN557AMERICORP INS. COPO BOX 3430CARMELIN460828666994186D51AMERIGROUP COMMUNITY CAREPO BOX 61010VIRGINIA BEACHVA2346610108006004441 MEDICAID HMOD94AMERIGROUP COMMUNITY CAREPO BOX 61010VIRGINIA BEACHVA2346610108006004441 MEDICAID HMOD60AMERIGROUP COMMUNITY CARE OF SCPO BOX 31789VIRGINIA BEACHVA2346617898006004441 CODE ASSIGNED BY SCHA284AMERIHEALTH ADMINISTRATORS720 BLAIR RD.HORSHAMPA19044110AMERIHEALTH HMO, INC.PO BOX 41574PHILADELPHIAPA191011574894AMERIHEALTH MERCY HEALTH PLANPO BOX 7118LONDONKY40742A10AMERISCRIPT4301 DARROW RD., STE.4200STOWOH442248889917200 CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA8006816912210AMERITAS LIFE INSURANCEPO BOX 82520LINCOLNNE685018002559678B08AMFIRST INSURANCE COPO BOX 16708JACKSONMS392368888882519653ANDERSON COUNTY330ANNUITY BOARD OF SOUTHERN BAPTISTCONVENTIONPO BOX 2190NASHVILLETN372342147200511X0YANTHEM BLUE CROSS AND BLUE SHIELDPO BOX 105187ATLANTAGA303488005529159X0YDN ANTHEM BLUE CROSS AND BLUE SHIELDPO BOX 659444SAN ANTONIOTX7826580062248228006927338 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA80034540178886323862 CODE ASSIGNED BY SCHAAppendix 2-6
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENTX0YRX ANTHEM BLUE CROSS AND BLUE SHIELDPO BOX 37010LOUISVILLEKY402338006224822529ANTHEM HEALTH3575 KROGER BLVD., STE.400DULUTHGA303168008881966579ANTHEM PRESCRIPTION MANAGEMENTPO BOX 145433CINCINNATIOH452508006620210 USE CARRIER A24D65ANTHEM SENIOR ADVANTAGEPO BOX 37690LOUISVILLEKY402337180171AONPO BOX 66WINSTON-SALEMNC271028003683804523APA PARTNERS, INC.PO BOX 1506LATHAMNY1211080068008333650705APS HEALTHCARE, INC.PO BOX 1307ROCKVILLEMD208498002218699D13ARCADIANPO BOX 4946COVINACA917238007756490 CODE ORIGINALLY ASSIGNEDAS MA IN ERROR USE CODE 816FOR MA PLAN816ARCADIAN MEMBER CAREPO BOX 4946COVINACA917238005738597 MEDICARE ADVANTAGE PLAN981ARGUS HEALTH SYSTEMSPO BOX 419019KANSAS CITYMO641418005227487A49ARIZONA FOUNDATION FOR MEDICAL CAREPO BOX 2909PHOENIXAZ850622909X1IARKANSAS BLUE CROSS AND BLUE SHIELD, INC.PO BOX 2181LITTLE ROCKAR722035013782010B78ARM GROUP (OMNICARE)340 QUADRANGLE DR.BOLINGBROOKIL604408009687222972ASR CORP (ADMINISTRATION SYSTEM RESEARCH)PO BOX 6392GRAND RAPIDSMI495168009682449505ASSOCIATED ADMINISTRATORSPO BOX 27806BALTIMOREMD2128578068006382972898ASSOCIATION & SOCIETY INS. CORPPO BOX 2510ROCKVILLEMD208478006382610934ASSOCIATION & SOCIETY INS. CORPPO BOX 2510ROCKVILLEMD208478006382610458ASSOCIATION BENEFIT PLAN (MEDICARE)PO BOX 668587CHARLOTTENC2826685878006340069 CODE ASSIGNED BY SCHA386ASSURANT HEALTHPO BOX 624MILWAUKEEWI532010624MILWAUKEE WAS FORTIS INSURANCECOMPANY386DNASSURANT HEALTHPO BOX 2940CLINTONIA5273329408004427742 DHHS INTERNAL RECOVERYCLAIMS BILLING MUST BE FAXTO: 414-224-0472448ASSURANT HEALTH INSURANCEPO BOX 42033HAZELWOODMD630428005537654 CODE ASSIGNED BY SCHA451ASSURECARE RISK MANAGEMENT340 QUADRANGLE BLVD.BOLINGBROOKIL604408007597422105ATHENE ANNUITY AND LIFE ASSURANCE COMPANYPO BOX 19038GREENVILLESC2960286460910008882909160 MEDICARE ADVANTAGE PLAN6022318855 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHAAppendix 2-7
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENT971ATLANTA ADMINISTRATIONS135 BEAVER ST.WALTHAMMA024528005481256B34ATLANTA LIFE INSURANCE COMPANY100 AUBURN AVE., NEATLANTAGA303034046592100122ATLANTIC COAST LIFE INSURANCE COMPANYPO BOX PO BOX 613HAMMONTONNJ080378883282287526AULTCAREPO BOX 6910CANTONOH447068003448858588AUTOMATED BENEFIT SERVICES, INC.PO BOX 321223DETROITMI482321223B82AVANTE HEALTH1111 E. HERNDON AVE.,STE. 308FRESNOCA937208664163617C40AVERA HEALTH PLANSPO BOX 381506BIRMINGHAMAL352388883222115 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA494AVESIS PHARMACY NETWORK3724 N 3RD ST., STE. 300PHOENIXAZ850126022413400B58AVMED HEALTHPO BOX 569000MIAMIFL3325690008004528633A72BABB, INC.850 RIDGE AVE.PITTSBURGHPA152128002456102358BAKERY & CONFECTIONERY UNION10401 CONNECTICUT AVE., KENSINGTONSTE. 300MD2089539603014683742654BAMBERG COUNTY987BANKERS FIDELITY LIFE INS COPO BOX 105652ATLANTAGA303484042665500815BANKERS FIDELITY LIFE INSURANCE COMPANYPO BOX 260040PLANOTX750268664587499 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA123BANKERS LIFE & CASUALTYPO BOX 66927CHICAGOIL606660927655BARNWELL COUNTY644BCBS OF GEORGIA8002751896 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA8006213724PO BOX 9907COLUMBUSGA319088004412273 MEDICARE INTERMEDIARYX0BDN BCBS OF GEORGIA DENTALPO BOX 659444SAN ANTONIOTX782654048428000X0MDN BCBS OF MASSACHUSETTSPO BOX 986005BOSTONMA022988002535210 DENTAL ONLY867BCBS OF NCPO BOX 30087DURHAMNC277029194897431C62BCBS OF SC MEDICARE BLUE PRIVATE (PFFS)PO BOX 100133COLUMBIASC292028006053256 MEDICARE ADVANTAGE PLANC63BCBS OF SC MEDICARE BLUE&MEDICARE BLUEPLUS (PPO)BCBS OF TENNESSEEPO BOX 100133COLUMBIASC292028006053256 MEDICARE ADVANTAGE PLAN730 CHESTNUT ST.CHATTANOOGATN374028772966189 MEDICARE INTERMEDIARY643Appendix 2-8
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIP656BEAUFORT COUNTY881C08PHONE NUM CARRIER COMMENTBEHAVIORAL HEALTH SYSTEMSPO BOX 830724BIRMINGHAMAL3528307248002451150BENECARDPO BOX 2187CLIFTONNJ070158007379528750BENEFIT ADMINISTRATIV E SERVICESPO BOX 4509ROCKFORDIL611108159699663C79BENEFIT ADMINISTRATIV E SYSTEM, LTDPO BOX 17475 JOVANNADR., STE. 1BHOMEWOODIL604307087997400E87BENEFIT ADMINISTRATIV E SYSTEMSPO BOX 2920MILWAUKEEWI532018005250582B37BENEFIT ADMINISTRATORSPO BOX 21308COLUMBIASC292218778400936B37DN BENEFIT ADMINISTRATORSPO BOX 1957BEATTYVILLEKY413118003258424300BENEFIT ADMINISTRATORS, INC.PO BOX 6279ERIEPA165128007772524300DNBENEFIT ADMINISTRATORS, INC.PO BOX 6279ERIEPA165128007772524475BENEFIT ASSISTANCE CORP.PO BOX 950HURRICANEWV255263045621913319BENEFIT CONCEPTSPO BOX 60608KING OF PRUSSIAPA194068002202600F29DNBENEFIT COORDINATORSPO BOX 210546COLUMBIASC292218037220110 DENTALF29BENEFIT COORDINATORSPO BOX 210546COLUMBIASC292218037220110A86BENEFIT MANAGEMENT COPO BOX 269000WESTONFL333269000C12BENEFIT MANAGEMENT, INC.PO BOX 1090GREAT BENDKS662108002901368301BENEFIT PLAN ADMINISTRATORSPO BOX 21392EAGENMN551218002778973C28BENEFIT PLAN MANAGEMENTPO BOX 536ROCKLYNMA023708776427500311BENEFIT PLANNERS, INC.PO BOX 682010SAN ANTONIOTX782692106991872980BENEFIT SUPPORT, INC.PO BOX 2977GAINESVILLEGA305038007774782772BENEFIT SYSTEMS, INC.PO BOX RCE, INC.PO BOX 240MONROEMI481618004231028 CODE ASSIGNED BY SCHAA25BENESCRIPT8300 E. MAPLEWOOD AVE.GREENWOOD VILLAGECO801118003453189985BENESIGHTPO BOX 340PUEBLOCO810028003621116A81BENESYSPO BOX 90082LUBBOCKTX794023372341789256BENICOMP8310 CLINTON PARK DR.FT. WAYNEIN468258008377400 CODE ASSIGNED BY SCHA8002629175 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHAAppendix 2-9
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIP380BENMARK, INC.PO BOX 16767JACKSONMS392366013660596481BENOVATION3481 CENTRAL PARKWAY,STE. 200CINCINNATIOH452238006816912 CODE ASSIGNED BY SCHA657BERKELEY COUNTY904BEST CHOICE HEALTH PLANPO BOX 21128FORT LAUDERDALEFL333358008674446E29BEST LIFE AND HEALTH INSURANCE CO.PO BOX 890MERIDIANID8368008908004330088D08BIG LOTS ASSOCIATE BENEFIT PLANPO BOX 9071DUBLINOH4301709718772542363 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHAX2XBLUE CROSS BLUE SHIELD OF HAWAIIPO BOX 44500HONOLULUHI968018007764672902BLUE CARE NETWORK OF MIPO BOX 68710GRAND RAPIDMI495168006588878 CODE ASSIGNED BY SCHA.THIS IS THE HMO TO CC 504WHICH IS THE POSC64BLUE CHOICE HEALTH PLAN (PPO)PO BOX 6170COLUMBIASC292608772753256 MEDICARE ADVANTAGE (PPO)922BLUE CHOICE HEALTHPLANPO BOX 6170COLUMBIASC292606170403BLUE CHOICE/MEDICAIDPO BOX 6170COLUMBIASC29260X2GBLUE CROSS & BLUE SHIELD CENTRAL NEW YORK,INC.PO BOX 4809SYRACUSENY1322148093154483801X2WBLUE CROSS & BLUE SHIELD OF ARIZONA, INC.PO BOX 13466PHOENIXAZ8500234666028644100X1VBLUE CROSS & BLUE SHIELD OF COLORADO700 BROADWAYDENVERCO802733038312131X1HBLUE CROSS & BLUE SHIELD OF CONNECTICUT, INC. PO BOX 533NORTH HAVENCT064732032394961X0LBLUE CROSS & BLUE SHIELD OF DELAWARE, INC.WILMINGTONDE198993024210260X0BBLUE CROSS & BLUE SHIELD OF GEORGIA/ATLANTA, PO BOX 9907INC.COLUMBUSGA319086007X1MBLUE CROSS & BLUE SHIELD OF KANSAS1133 SOUTHWEST TOPEKABLVD.TOPEKAKS666297852914180X2BBLUE CROSS & BLUE SHIELD OF KANSAS CITYPO BOX 419169KANSAS CITYMO6414161698008926048X0UBLUE CROSS & BLUE SHIELD OF KENTUCKY, INC.9901 LINN STATION RD.LOUISVILLEKY402235024232011X1LBLUE CROSS & BLUE SHIELD OF LOUISIANAPO BOX 98029BATON ROUGELA7089890295042915370PO BOX 1991PHONE NUM CARRIER COMMENT8037868466 WAS COMPANION HEALTHCARENAME CHANGE EFFECTIVE7/1/058772753256 MEDICAID HMO4048428000 FOR GEORGIA STATEEMPLOYEES USE CARRIER 419GEORGIA STATE HEALTHBENEFIT PLANAppendix 2-10
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPX1QBLUE CROSS & BLUE SHIELD OF MAINE2 GANNETT DR.SOUTH PORTLANDME0410669112077751550X01BLUE CROSS & BLUE SHIELD OF MARYLAND, INC.PO BOX 14115LEXINGTONKY405128005244555X0IBLUE CROSS & BLUE SHIELD OF MARYLAND, INC.PO BOX 9836BALTIMOREMD212048005244555 USE CARRIER X01X1KBLUE CROSS & BLUE SHIELD OF MEMPHIS85 NORTH DANNY THOMAS MEMPHISBLVD.TN381039015293111X0QBLUE CROSS & BLUE SHIELD OF MICHIGANPO BOX 312500DETROITMI482318004820898X0QDN BLUE CROSS & BLUE SHIELD OF MICHIGANPO BOX 49DETROITMI482318888268152X1PBLUE CROSS & BLUE SHIELD OF MINNESOTAPO BOX 64338ST. PAULMN551648003822000X0ZBLUE CROSS & BLUE SHIELD OF MISSISSIPPI, INC.PO BOX 1043JACKSONMS392156016644590X2UBLUE CROSS & BLUE SHIELD OF MISSOURI1831 CHESTNUT ST.ST. LOUISMO631033149234444 AKA ALLIANCE BLUE CROSSBLUE SHIELDX1UBLUE CROSS & BLUE SHIELD OF NEBRASKAPO BOX 3248,MAIN PO STATIONOMAHANE681800001X0SBLUE CROSS & BLUE SHIELD OF NEW JERSEY, INC.PO BOX 1219NEWARKNJ07101X0SDN BLUE CROSS & BLUE SHIELD OF NEW JERSEY, INC.PO BOX 1311MINNEAPOLISMN55440X0CBLUE CROSS & BLUE SHIELD OF NORTH CAROLINAPHONE NUM CARRIER COMMENT40239018208006241110 AKA HORIZON BCBS OF NEWJERSEY8003552583 AKA HORIZON BCBS OF NEWJERSEY8002144844PO BOX 35DURHAMNC27702X0CDN BLUE CROSS & BLUE SHIELD OF NORTH CAROLINAPO BOX 2100WINSTON-SALEMNC2710221009194897431X2JBLUE CROSS & BLUE SHIELD OF NORTH DAKOTA4510 13TH AVE. SWFARGOND5812100018003682312X2TBLUE CROSS & BLUE SHIELD OF OKLAHOMAPO BOX 3283TULSAOK741029185603535X1FBLUE CROSS & BLUE SHIELD OF RHODE ISLAND500 EXCHANGE ST.PROVIDENCERI029034018317300X0PBLUE CROSS & BLUE SHIELD OF TENNESSEE1 CAMERON HILL CIRCLECHATTANOOGATN3740200028004689736X0PDN BLUE CROSS & BLUE SHIELD OF TENNESSEE1 CAMERON HILL CIRCLESTE. 0002CHATTANOOGATN3740200028005659140X1WBLUE CROSS & BLUE SHIELD OF UTAHPO BOX 30270SALT LAKE CITYUT8413002708013332100X2HBLUE CROSS & BLUE SHIELD OF UTICAWATERTOWN, INC.12 RHOADS DR., UTICABUSINESS DISTRICTUTICANY135013157984238X2SBLUE CROSS & BLUE SHIELD OF VERMONTPO BOX 2365SOUTH BURLINGTONVT540723658022472583X0FBLUE CROSS & BLUE SHIELD OF VIRGINIAPO BOX 27401RICHMONDVA232798009916061Appendix 2-11
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENTX2OBLUE CROSS & BLUE SHIELD OF WEST VIRGINIA,INC.PO BOX 1353CHARLESTONWV253253043477709X1JBLUE CROSS & BLUE SHIELD OF WESTERN NEWYORK, INC.PO BOX 80BUFFALONY1424000808008880757X0HBLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN PO BOX 2025MILWAUKEEWI532014142246100X1DBLUE CROSS /BLUE SHIELD OF NATIONAL CAPITALAREA550 12TH ST. SWWASHINGTONDC200242024798000X0OBLUE CROSS AND BLUE SHIELD OF ALABAMAPO BOX 2294BIRMINGHAMAL35201X0ODN BLUE CROSS AND BLUE SHIELD OF ALABAMAPO BOX 830389BIRMINGHAMAL3528303898005176425 DO NOT USE FOR MEDICARE.THIS CODE IS ONLY USED FORHEALTH RELATED COVERAGE.8005176425X0DBLUE CROSS AND BLUE SHIELD OF FLORIDAPO BOX 1798JACKSONVILLEFL3223100148007272227401BLUE CROSS AND BLUE SHIELD OF SCPO BOX 100300COLUMBIASC292028037883860 DO NOT USE FOR MEDICARE.THIS CODE IS ONLY USED FORHEALTH RELATED COVERAGE.STREET ADDRESS 4101CERVICAL RD. COLA 29219401DNBLUE CROSS AND BLUE SHIELD OF SC4101 PERCIVAL RD.COLUMBIASC292198037883860 THIS CODE USED ONLY FORDENTAL CLAIMS WHERE BCBSIS THE INSURANCE CARRIERX0NBLUE CROSS AND BLUE SHIELD OF TEXASPO BOX 660044DALLASTX7526600448004510287X0NDN BLUE CROSS AND BLUE SHIELD OF TEXASPO BOX 660247DALLASTX752668004947218X2FDN BLUE CROSS AND BLUE SHIELD OF THEROCHESTER AREAPO BOX 22999ROCHESTERNY146927163253630 DENTAL453BLUE CROSS ANTHEM MEDICARE ADVANTAGE2100 CORPORATE CENTERNEWBURY PARKCA913201431X2YBLUE CROSS BLUE SHIELD OF MONTANAPO BOX 5004GREAT FALLSMT594034067914000X1ABLUE CROSS BLUE SHIELD OF NEW MEXICO80071137958006762583 MEDICARE ADVANTAGE PLANPO BOX 27630ALBUQUERQUENM87125X1FDN BLUE CROSS BLUE SHIELD OF RHODE ISLANDPO BOX 69427HARRISBURGPA171069427F49BLUE CROSS BLUE SHIELD OF WYOMINGPO BOX 2266CHEYENNEWY820038004422376F49DNBLUE CROSS BLUE SHIELD OF WYOMINGPO BOX 2266CHEYENNEWY820038004422376 DENTAL ONLYX0WBLUE CROSS OF CALIFORNIAPO BOX 60007LOS ANGELESCA900608006776669D67BLUE CROSS OF FLORIDA HEALTH OPTIONSPO BOX 1798JACKSONVILLEFL322318773522583 MEDICARE ADVANTAGE PLAN8008312400 DENTAL ONLYAppendix 2-12
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPX0ABLUE CROSS OF GEORGIA/COLUMBUS, INC.PO BOX 9907COLUMBUSGA3190899078004412273 POLICIES SHOULD BE ADDEDWITH XOB. BCBS OF OF GA.X0ARX BLUE CROSS OF GEORGIA/COLUMBUS, INC.PO BOX 9907COLUMBUSGA319089907X2VPO BOX 7408BOISEID837078004412273 DO NOT USE FOR MEDICARE.THIS CODE IS ONLY USED FORHEALTH RELATED COVERAGE.2083447411X2VDN BLUE CROSS OF IDAHO HEALTH SERVICEPO BOX 7408BOISEID837072083447411 DENTAL ONLYX0TBLUE CROSS OF IDAHO HEALTH SERVICE, INC.BLUE CROSS OF ILLINOISPHONE NUM CARRIER COMMENTPO BOX 805107CHICAGOIL606808006348644X0TDN BLUE CROSS OF ILLINOISPO BOX 23059BELLEVILLEIL622238668260914X0MBLUE CROSS OF MASSACHUSETTS, INC.PO BOX 986020BOSTONMA0229860208002535210XOVBLUE CROSS OF NORTHEASTERN NEW YORK, INC.PO BOX 15013ALBANYNY122125184385500X2LBLUE CROSS OF NORTHEASTERN PENNSYLVANIAPO BOX 890179CAMP HILLPA1708901798008298599X1XBLUE CROSS OF OHIOPO BOX 956TOLEDOOH436968003621279X1EBLUE CROSS OF PUERTO RICOPO BOX 366068SAN JUANPR0093660688097599898X2MBLUE CROSS OF WASHINGTON AND ALASKAPO BOX 91059SEATTLEWA9811191598007221471X1YDN BLUE SHIELD OF CALIFORNIAPO BOX 272590CHICOCA9592725908887024171X1YBLUE SHIELD OF CALIFORNIAPO BOX 272540CHICOCA959278882351765X0VBLUE SHIELD OF NORTHEASTERN NEW YORKPO BOX 15013ALBANYNY122125184534600D41BLUEGRASS FAMILY HEALTHPO BOX 22738LEXINGTONKY405228007872680390BOARD OF PENSIONS EVANGELICAL LUTHERANCHURCHPO BOX 59093MINNEAPOLISMN5545900936123337651337BOARD OF PENSIONS OF THE PRESBYTERIANCHURCH OFPO BOX 13896PHILADELPHIAPA191018007737752404BOB JONES UNIVERSITY1700 WADE KERS NATIONAL HEALTH & WELFAREFUND754 MINNESOTA AVE., STE.522KANSAS CITYKS6610127629133426555739BOLLINGER, INC.PO BOX 727SHORT HILLSNJ070788662670092702BOON CHAPMAN BENEFIT ADMINISTRATORSPO BOX 9201AUSTINTX7876692018002529653 CODE ASSIGNED BY SCHAAUSTINTX7876692018002529653 DENTAL ONLY702DNBOON CHAPMAN BENEFIT ADMINISTRATORSPO BOX 9201Appendix 2-13
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENTF53BOON GROUPPO BOX 559017AUSTINTX787558664750056 ADDED BY SC REVENUE ANDFISCAL AFFAIRSC22BOSTON MUTUAL LIFE INSURANCE COMPANY120 ROYALL ST.CANTONMA020216178287000854BOYD CARE (BOYD BROTHERS TRANSPORTATION)PO BOX 70CLAYTONAL360163347751284D58BRAVO HEALTH MEDICARE ADVANTAGEPO BOX 4433BALTIMOREMD212238005561570 MEDICARE ADVANTAGE PLAN294BRIDGESTONE/FIRESTONE COMPANIESPO BOX 26605AKRONOH443198002378447E89BROADREACH MEDICAL RESOURCES1350 BROADWAY #410NEW YORKNY100188887182375852BUILDERS MUTUAL INSURANCE COPO BOX 150006RALEIGHNC2762400068008094861E30BUSINESS ADMINISTRATORS AND CONSULTANTS,INC.PO BOX 107REYNOLDSBURGOH430688005212654304BUTLER BENEFIT SERVICE, INC.PO BOX 3310DAVENPORTIA5280833108669272200262CAIC (CONTINENTAL AMERICAN INS. CO)PO BOX 6080226MISSION VIEJOCA9269060808887302244658CALHOUN COUNTY973CAMBRIDGE INTEGRATED SERVICES GROUP, INC.PO BOX 1687GRAND RAPIDSMI495018007669780 USE CARRIER 171 AON832CAMERON AND ASSOCIATES6100 LAKE FOREST DR.ATLANTAGA303288003879919998CANADA LIFE ASSURANCE CO.6201 POWERS FERRY RD.,STE. 100ATLANTAGA303488003332542X2KCAPITAL BLUE CROSSPO BOX 211457EAGANMN5512130578009622242274CAPITAL DISTRICT PHYSICIANS PLANPO BOX 66602ALBANYNY1220666028009267526966CAPITOL ADMINISTRATORS OF THE SOUTHEASTPO BOX 188061CHATTANOOGATN374228886506566166CAPITOL AMERICAN LIFE INSURANCE COMPANYPO BOX 94953CLEVELANDOH4410149532166966400128CAPITOL LIFE INSURANCE COMPANYPO BOX 1200DENVERCO80201F18CARE CONNECTPO BOX 830259BIRMINGHAMAL352830259D42CARE IMPROVEMENT PLUSPO BOX 4347SCRANTONPA18505764CARE LINK HEALTH PLANPO BOX 7373LONDONKY4074273738003482922B92CARE SOURCEONE SOUTH MAINDAYTONOH454028004880134F56CAREFIRST BLUECHOICE MARYLANDPO BOX 14116LEXINGTONKY405128008425975 ADDED BY SC REVENUE ANDFISCAL AFFAIRS151CARELINKPO BOX 7373LONDONKY407428003482922 MEDICAID HMO8005252115 PER HOSP. ASSO. 07/02, THIS ISSTILL A VALID CARRIER85570675458666862506 MEDICARE ADVANTAGE PLANAppendix 2-14
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIP471CAREMARKPO BOX 52195PHOENIXAZ8507221958003030187280CAREMARK PRESCRIPTION SERVICESPO BOX 52188PHOENIXAZ8507221968008415550 USE CARRIER 471903CAREPLUS HEALTH PLANPO BOX 31286TAMPAFL3363132868008674445 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHAB04CARITEN HEALTHCAREPO BOX 22987KNOXVILLETN379338002840042 CODE IN OPEN STATUS BYSCHAD21CARITEN SENIOR HEALTHPO BOX 22885KNOXVILLETN379338656707790 MEDICARE ADVANTAGE PLAN945CAROLINA ATLANTIC MEDICAL SERVICESORGANIZATIONPO BOX 22528CHARLESTONSC294138008100906 DORMANT 8/06A71CAROLINA BEHAVIORAL HEALTH ALLIANCEPO BOX A BENEFIT ADMINISTRATORSPO BOX 3257SPARTANBURGSC293048645736937445CAROLINA CARE PLAN/MEDICAL MUTUAL INS. CO.OF OHIOPO BOX 6018CLEVELANDOH4410110188003153143 ALSO KNOWN AS SUPERMEDANOTHER PHONE # 800-2323143445DNCAROLINA CARE PLAN/MEDICAL MUTUAL INS. CO.PO BOX 6018CLEVELANDOH441011018800315314723CAROLINA CONTINENTAL INSURANCEPO BOX 427COLUMBIASC292028032566265E12CAROLINA CRESCENT1201 MAIN ST., STE. 970COLUMBIASC292018032516630 HEALTHY KIDS CONNECTION559CAROLINA HOSPITAL SYSTEMS BENEFIT PLANPO BOX 100569FLORENCESC295010659623CAROLINA MEDICARE PRIME HMO201 EXECUTIVE CENTERDR.COLUMBIASC292108037507473 MEDICARE ADVANTAGE PLANC77CARPENTERS HOSPITALIZATION PLAN3611 CHESTER AVE.CLEVELANDOH441148004213959 THIS CODE NOT REQUESTED BYMEDICAID. ASSIGNED BY SCHA336CASEBP (CATSKILL AREA SCHOOLS EMPLOYEEPLAN)CASTIARXPO BOX 968022SCHAUMBERGIL601968009626294701 EMERSON RD., STE.301CREVE UALTY CASE366CATALYST RXPO BOX 968022SCHAUMBERGIL572CATAMARANPO BOX 29044HOT SPRINGSAR71093C66CATERPILLAR, INC.PO BOX 62920COLORADO SPRINGSCO809622920C04CBA BLUEPO BOX 9350SOUTH BURLINGTONVT05407PHONE NUM CARRIER COMMENTDENTAL ONLY84366138758778398119 FORMERLY HEALTH TRANS30949423638882229206 DENTAL ONLYAppendix 2-15
South Carolina Healthy Connections (Medicaid)03/01/19APPENDIX 2 CARRIER CODESCARRIER CODES: ARRANGED ALPHABETICALLYCARRTPL NAMEADDRESS LINECITYSTZIPPHONE NUM CARRIER COMMENTB11CBCA ADMINISTRATORS, INC.PO BOX 1339MINNEAPOLI
f27 3padministrators po box 247 onalaska wi 54650 6087793000 dental only b14 a.c.s. consulting services, inc. po box 2000 winston-salem nc 271022000 3367592013 . south carolina . carr tpl name address line city st zip phone num carrier comment b14dn a.c.s. consulting services, inc. po box 2000 winston-salem nc 271022000 3367592013 dental only .
