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PennsylvaniaPROMISe Companion Guide820Payroll Deducted and Other GroupPremium Payment for InsuranceProductsVersion 5010July 2015, Version 1.11
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCopyright Notice and DisclaimerThis document is Copyright 2010 by The Workgroup for Electronic Data Interchange(WEDI) and the Data Interchange Standards Association (DISA), on behalf of theAccredited Standards Committee (ASC) X12. All rights reserved. It may be freelyredistributed in its entirety provided that this copyright notice is not removed. It may notbe sold for profit or used in commercial documents without the written permission of thecopyright holder. This document is provided “as is” without any express or impliedwarranty. Note that the copyright on the underlying ASC X12 Standards is held by DISAon behalf of ASC X12.Express permission to use ASC X12 copyrighted materials has been granted.July 2015
Pennsylvania PROMISe – 820 Premium Payment Companion GuideRevision HistoryDocumentVersion NumberVersion 1.1Version 1.2RevisionDate06/01/1007/08/10Reason for RevisionsRevisions Completed ByNew documentLoop updatesDocumentation TeamDocumentation TeamVersion 1.307/14/10Loop updatesDocumentation TeamVersion 1.409/19/12Documentation TeamVersion 1.510/25/12Version 1.6Version 1.7Version 1.8Version 1.912/07/1201/09/1312/23/1309/12/14Version 1.1004/10/15Version 1.1107/09/15Updated Carrier List inAppendix ARemoved PH/95 from CarrierList in Appendix ARemoved namesUpdated Appendix AUpdated Appendix AUpdated Appendix A andadded Copyright Notice andDisclaimer pageUpdated logo and name fromDPW to DHS; UpdatedAppendix A – InsuranceCarriers, section “PROMISe specific HIPAA DataElements” was updated toalign with ASC X12guidelinesUpdated TR3 name/uniqueidentifierJuly 2015Documentation TeamDocumentation TeamDocumentation TeamDocumentation TeamDocumentation TeamDocumentation TeamDocumentation Team
Pennsylvania PROMISe – 820 Premium Payment Companion GuideTableofContentsOverview . 1Companion Guide Instructions . 2Revisions to the Companion Guide . 3Pennsylvania-Specific HIPAA Data Elements . 4Appendix A – Insurance Carriers . 5July 2015
Pennsylvania PROMISe – 820 Premium Payment Companion GuideOverviewThe Pennsylvania Department of Human Services’ HIPAA-compliant Provider Reimbursementand Operations Management Information System (PROMISe ) has adopted the new version5010 X12 standards. These standards are in compliance with the CMS mandate effectiveJanuary 1, 2012.This Companion Guide contains detailed instructions for interpreting the ASC X12 005010X218Payroll Deducted and Other Group Premium Payment for Insurance Products (820) transactionrecords that are be received from PROMISe . Please disregard any instructions that do notpertain to the services you are receiving.July 2015Page 1
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCompanionGuideInstructionsOne of the new terms born out of HIPAA is payer variability. As each payer works to make itssystem HIPAA ready, there is a realization and an allowance that payers use information andvalues/formats specific to their systems. This companion guide was developed to communicatethe Pennsylvania Medical Assistance-specific information required to accurately interpret the820 Premium Payment capitation transactions as created by PROMISe .This Companion Guide is to be used in conjunction with the ASC X12 Implementation Guide(found at http://store.x12.org). The ASC X12 Implementation Guide takes precedence and isthe main source of information about the transaction sets.The companion guide contains DHS interpretation/application of the data elements that support medical assistancetransaction submissions, The methods utilized to convey data that are not included in the ASC X12Implementation Guide, but are required for processing Pennsylvania Department ofHuman Services transactions; and Clarification for certain, less obvious, but still standard, uses of the transaction.July 2015Page 2
Pennsylvania PROMISe – 820 Premium Payment Companion GuideRevisions to theCompanion GuideTo aid the provider community in organizing these companion guides and the revisions thatmay occur, this document will have a revision schedule and notification process.The initial release of this companion guide is June 2010. The first release reflected all theknown information as of this date. However, as the implementation phases of PROMISe progress, updates and releases of new information may be forthcoming.The e-mail information that you provided when you downloaded this Companion guide will beused to notify you when the regularly scheduled updates are available, as well as when thereare any special updates in between. If your email information changes, please notify HPEnterprise Services at papac1@hp.com.Revision Process:For each new release of this companion guide, the information that has been changed sincethe previous version will be located in that specific section of the guide. If a revision is made toa data element, it will be detailed in the Revision(s) Description section in the table containingthe element. DHS will clearly define the change that was made so it can be integrated into yourprocess.If there are any updated releases of the Companion Guide, DHS will attempt to notify you of itsavailability through the email address that you supplied when you registered for PROMISe certification. Updates will also be posted to the DHS web site. Please check for these updatesregularly.July 2015Page 3
Pennsylvania PROMISe – 820 Premium Payment Companion GuidePennsylvaniaSpecific HIPAAData ElementsPage#PROMISe SpecificField NameC.5ISA06: Interchange Sender IDProduction - "345529167"Testing - "445314156"C.7GS02: Application Sender's CodeProduction - "345529167"Testing - "445314156"40BPR10: Originating Company Identifier"1236003113"65N104: Identification Code"236003113"(LOOP 1000B: Premium Payer’s Name)113RMR02:Reference IdentificationRate Cell, County Code, Adjustment Reason Code,Adjusted Rate Cell Age, Category, Program Status Code, MedicareIndicator related to the Rate Cell Field Age, Category, Program Status Code, MedicareIndicator related to the Adjusted Rate CellJuly 2015Page 4
Pennsylvania PROMISe – 820 Premium Payment Companion GuideAppendix A – Insurance CarriersInsurance Listings with Addresses:Carrier CodeJuly 2015Carrier NameAddress001Aetna Better Health (PCO)2000 Market Street, Suite 850Philadelphia, PA 19103-3231002Capital Blue CrossSecureChoice (PCO)2500 Elmerton AvenueHarrisburg, PA 17177-9799003Gateway Healthplus (PCO)Four Gateway Center444 Liberty Avenue, Suite 2100Pittsburgh, PA 15222-1222004Geisinger Healthy Connect(PCO)108 Woodbine LaneDanville, PA 17821-9118005Health Partners Essential(PCO)901 Market Street, Suite 500Philadelphia, PA 19107-4496006Keystone Connect (PCO)200 Stevens DrivePhiladelphia, PA 19113007UnitedHealthcareCommunity Plan for Adults(PCO)1001 Brinton RoadPittsburgh, PA 15221-4533008UPMC for Best Health(PCO)600 Grant Street, 55th FloorPittsburgh, PA 15219-2702009AmeriHealth Connect (PCO) 200 Stevens DrivePhiladelphia, PA 19113100Medicare Part B103Medicare Part DPage 5
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddress200Independence Blue Cross1901 Market StreetPhiladelphia, PA 19103201Highmark Blue Cross/BlueShieldFifth Avenue Place120 Fifth Ave/Suite P3105Pittsburgh, PA 15222202Capital Blue Cross2500 Elmerton AvenueHarrisburg, PA 17177203Blue Cross of N.E. PA19 N Main StreetWilkes-Barre, PA 18711240Security 65 IndependencePlan1901 Market StreetPhiladelphia, PA 19103241Security 65 Highmark Plan5th Avenue PlacePittsburgh, PA 15222242Security 65 Capital PlanDept 778995Harrisburg, PA 17177-8995243Security 65 Northeast Plan70 N Main StreetWilkes-Barre, PA 18711244Highmark Service Company 5th Avenue Place120 5th Avenue Place/Suite P3105Pittsburgh, PA 15222249Blue Cross Medigap (out-ofstate)299Blue Cross Out of State300PA Blue ShieldPO Box 898206Camp Hill, PA 17089-0400300PA Blue ShieldPO Box 890500Camp Hill, PA 17089-0500Page 6
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddress300PA Blue ShieldPO Box 890062Camp Hill, PA 17089-0062340Blue Shield Medigap Security 65PO Box 898845Camp Hill, PA 17089-8845349Blue Shield Medigap (out-ofstate)399Blue Shield Out Of State400TRICARE/United Concordia TDP Claims ProcessingPO Box 69411Harrisburg, PA 17106400TRICAREPalmetto GBAPO Box 7011Camden, SC 29020400TRICARE/Express ScriptsPO Box 390007Bloomington, MN 55439401ChampVAPO Box 65023Denver, CO 80206-9023401ChampVAPO Box 65023Denver, CO 80206-9023500Personal Choice65/Keystone 65 (MedicareAdvantage)1901 Market StreetPhiladelphia, PA 19103501Freedom Blue (MedicareAdvantage)120 Fifth Avenue, Suite P5501Pittsburgh, PA 15222502Capital SeniorBlue(Medicare Advantage)2500 Elmerton AvenueHarrisburg, PA 17177503Senior Partners Terminated PO Box 5194Page 7
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddress7/31/07 now 516New York, NY 10004-5194504SecurityBlue (MedicareAdvantage)120 Fifth Avenue, Suite P5501Pittsburgh, PA 15222505Aetna (MedicareAdvantage)151 Farmington AvenueHartford, CT 06156506Gateway Health PlanMedicare Assured(Medicare Advantage)600 Grant Street, 41st FloorPittsburgh, PA 15219507Humana (MedicareAdvantage)101 East Main StreetLouisville, KY 40202509Advantra (MedicareAdvantage)11 Stanwix Street, Suite 2300Pittsburgh, PA 15222510Sterling Option 1 (Medicare 2219 Rimland DriveAdvantage)PO Box 5348Bellingham, WA 98226511Geisinger Health Plan(Medicare Advantage)100 North Academy AvenueDanville, PA 17822512AmeriHealth 65 (MedicareAdvantage)1901 Market StreetPhiladelphia, PA 19103513UnitedHealthCareCommunity Plan DualComplete (formerly UnisonAdvantage)Termed 12/31/2013PO Box 8207Kingston, NY 12402514Keystone 65 Complete(Medicare Advantage)1901 Market StreetPhiladelphia, PA 19103515UPMC For Life (MedicareAdvantage)112 Washington PlacePittsburgh, PA 15219Page 8
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddress516Bravo Health Pennsylvania(Medicare Advantage)3601 O’Donnell StreetBaltimore, MD 21224517Today’s Options (MedicareAdvantage)4888 Loop Central Drive, Suite 900Houston, TX 77081518United HealthcareCompanies (MedicareAdvantage)13621 NW 12th StreetSunrise, FL 33323519Keystone SeniorBlue(Medicare Advantage)2500 Elmerton AvenueHarrisburg, PA 17177520WellCare (MedicareAdvantage)8735 Henderson RoadTampa, FL 33634521Horizon Blue Cross BlueShield of New Jersey(Medicare Advantage)3 Penn Plaza EastNewark, NJ 07105522Healthfirst Medicare Plan(Medicare Advantage)25 Broadway, 9th FloorNew York, NY 10004527Coventry Healthcare(Medicare Advantage)3721 Tecport DriveHarrisburg, PA 17106528Universal Health Care(Medicare Advantage)150 2nd Avenue North, Suite 400Saint Petersburg, FL 33701529Citrus Health Care(Medicare Advantage)5420 Bay Center Drive, Suite 250Tampa, FL 33609530GHI Medicare Choice(Medicare Advantage)441 Ninth AvenueNew York, NY 10001531UniCare (MedicareAdvantage)PO Box 9154Oxnard, CA 93031532Anthem Blue Cross/BlueShield (Medicare4241 Irwin Simpson Road,OHO205-A037Page 9
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddressAdvantage)Mason, OH 45040533Care Improvement Plus(Medicare Advantage)250 West Pratt Street, Suite 230Baltimore, MD 21201536USACare (MedicareAdvantage)259 Monroe AvenueRochester, NY 14607537HIP Health Plan of GreaterNew York (MedicareAdvantage)55 Water StreetNew York, NY 10041-8190538MD MedicareChoice(Medicare Advantage)5501 West Waters Avenue, Suite401Tampa, FL 33634539HealthMarkets CareAssured (MedicareAdvantage)9151 Boulevard 26North Richland Hills, TX 76180542CIGNA Medicare Access(Medicare Advantage)900 Cottage Grove RoadHartford, CT 06152543Universal American(Medicare Advantage)1001 Heathrow Park Lane, Suite5001Lake Mary, FL 32746544Keystone VIP ChoicePO Box 307Linthicum, MD 21090-0307545Health Partners Medicare901 Market Street, Suite 500Philadelphia, PA 19107598Unlisted MedicareAdvantage HMO’s600Medicare Part A700Delta Dental of PAOne Delta DriveMechanicsburg, PA 17055Page 10
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddress701Amalgamated Life Insurance 730 BroadwayCo.New York, NY 10003-9511703Allstate Insurance Co.704Bankers Life & Casualty Co. 222 Merchandise Mart PlazaChicago, IL 60654705United Concordia4401 Deer Path RoadHarrisburg, PA 17110706CONSECO11825 N Pennsylvania StreetCarmel, IN 46032707Combined Insurance Co. of 1000 Milwaukee AvenueAmericaGlenview, IL 60025708CIGNA900 Cottage RoadBloomfield, CT 06002709ArgusPO Box 419019Kansas City, MO 64141710Continental CasualtyInsurance Co.333 South WabashChicago, IL 60604711American General70 Pine StreetNew York, NY 10270712Eastern Life & HealthInsurance Co.25 Race AvenueLancaster, PA 17608713AXA Equitable LifeInsurance Co.PO Box 1047Charlotte, NC 28201714Inter-Co. Hospital Plan720 Blair Mill RoadHorsham, PA 1904460 Allstate Plaza S.Northbrook, IL 60062Page 11
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddress715Inter-Co. Phys. Service Plan 720 Blair Mill RoadHorsham, PA 19044716John Hancock Mutual LifeInsurance Co.PO Box 111Boston, MA 02117718Life Insurance Co. NorthAmerica1601 Chestnut StreetPhiladelphia, PA 19192719Lincoln Financial Group8801 Indian Hills DriveOmaha, NE 68114720Mass Mutual Life Insurance 1295 State StreetCo.Springfield, MA 01111721United Healthcare722Mutual of Omaha Insurance Mutual Of Omaha PlazaCo.Omaha, NE 68175723People Benefit LifeInsurance Co.724New York Life Insurance Co. 51 Madison AvenueNew York, NY 10010725Transamerica OccidentalInsurance Co.PO Box 2101Los Angeles, CA 90051-2101726Phoenix Mutual LifeInsurance Co.PO Box 22012Albany, NY 12201-2012727Provident Life/AccidentInsurance Co.Fountain SquareChattanooga, TN 37402728Prudential Insurance Co. ofAmerica751 Broad StreetNewark, NJ 07102PO Box 740800Atlanta, GA 30374Claims DepartmentValley Forge, PA 19493Page 12
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddress730Travelers InsuranceOne Town Square MPBHartford, CT 06183731National Association ofLetter Carriers20547 Waverly CourtAshburn, VA 20149732Washington NationalInsurance Co.PO Box 2004Carmel, IN 46032-3004733Paid Prescription (MEDCO) PO Box 6121Fair Lawn, NJ. 07410-0999734American Postal WorkersUnionPO Box 967Silver Spring, MD 20910735Accordia NationalPO Box 3262East Charleston, WV 25332736Employers Health Insurance PO Box 14610Co.Lexington, KY 40512-4610737Jefferson-Pilot LifeInsurance Co.PO Box 21008Greensboro, NC 27420738Philadelphia American LifeIns. Co.PO Box 4884Houston, TX 77210739Protective Life InsuranceCo.2801 HWY 280 SouthBirmingham, AL 35223740Commercial Medigap741AARP MedigapPO Box 740819Atlanta, GA 30374-0819742National VisionAdministratorsPO Box 1981East Hanover, NJ 07936-0981743Express ScriptsPO Box 390007Page 13
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeCarrier NameAddressBloomington, MN 55439July 2015744PEBTF150 S. 43rd Street, Suite 1Harrisburg, PA 17111-5700745National PharmaceuticalServicesPO Box 407Boystown, NE 68010746Eagle Managed CareTerminated 12/31/199930 Hunter LanePO Box 7011Camp Hill, PA 17011747PCS950 E. Shea BoulevardScottsdale, AZ 85260749CaremarkPO Box 686005San Antonio, TX 78268750Aetna HMO Health PLSEast/Central PAPO Box 981107El Paso, TX 79998-1107751Americhoice Personal Care PO Box 16000Plus Terminated 7/31/05Phoenix, AZ 85011-6000752Alliance Health Network1700 Peach StreetErie, PA 16501753Advantage Health Plan PA121 Seventh StreetPittsburgh, PA 15222-3408755Geisinger Health PlanPO Box 8200Danville, PA 17821-8200756Unison Advantage (3 Rivers) PO Box 1018Terminated 6/30/06Monroeville, PA 15146Use code 513.757HealthAmerica /HealthAssurance3721 Tecport DrivePO Box 67103Harrisburg, PA 17106Page 14
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddress759Healthguard of LancasterTerminated 2/1/2006280 Granite Run DriveLancaster, PA. 17601760First Priority Health19 N. Main StreetWilkes-Barre, PA 18711761Keystone Health PlanCentralPO Box 898812Camp Hill, PA 17089-8812762Keystone Health Plan East1901 Market StreetPhiladelphia, PA 19103763Keystone Health Plan West PO Box 898819Camp Hill, PA 17089765Prudential Health Care Plan PO Box 901Horsham, PA 19044766Healthnet of the NortheastPO Box 14700Lexington, KY 40512767Aetna/US HealthcarePittsburghTerminated 08/12/20055313 Campbells Run RoadPittsburgh, PA 15205768Aetna/US Healthcare/HMOPATerminated 08/12/2005PO Box 1109Blue Bell, PA 19422770Health Partners/SeniorPartners of Philadelphia(Terminated 6/30/06)Use code 503.PO Box 5194New York, NY 10004-5194771Horizon HealthcareTerminated 12/31/20001700 Market StreetPhiladelphia, PA 19103772HIP Health Plan of PA6 Neshaminy InterplexTrevose, PA 19053Page 15
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier NameAddress774UPMC Health Plan IncPO Box 2999Pittsburgh, PA 15230775Optimum Choice Inc of PAPO Box 930Frederick, MD 21705776Philcare Health Systems2005 Market StreetPhiladelphia, PA 19103777Health CentralTerminated 12/31/20012605 Interstate DriveHarrisburg, PA 17110778AmeriHealth HMO1901 Market StreetPhiladelphia, PA 19103779Health Plans of PA100 W Sproul Road – 3rd FloorSpringfield, PA 19064780Principal HealthCare of PA2751 Centerville RoadWilmington, DE 19808781Avalon Health Ltd.2500 Elmerton AvenueHarrisburg, PA 17110783Qualmed Plans For Health1835 Market StreetPhiladelphia, PA 19103784Physicians Care HMO651 East Park Drive, Suite 108Harrisburg, PA 17111798Other HMO799Commercial Insurance (NotOtherwise Listed)801Auto Insurance Terminated5/24/07802Workers’ CompensationPage 16
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier CodeJuly 2015Carrier Name803Black Lung Medical Benefits900Patient Pay902LTC Patient Pay903Transfer PenaltyAddressPage 17
Pennsylvania PROMISe – 820 Premium Payment Companion GuideAlphabetical Listing of Insurance Carriers:Carrier NameCarrier CodeAARP Medigap741Accordia National735Advantage Health Plan753Advantra (Medicare Advantage)509Aetna (Medicare Advantage)505Aetna Better Health (PCO)001Aetna HMO Health Plans East/Central PA750Alliance Health Network752Allstate Insurance Company703Amalgamated Life Insurance Co701American General Ins Co711American Postal Workers Union734Americhoice Personal Care Plus751AmeriHealth Connect (PCO)009AmeriHealth HMO778AmeriHealth 65512Anthem Blue Cross/Blue Shield (Medicare Advantage)532Argus709Auto Insurance801July 2015Page 18
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier NameCarrier CodeAvalon Health LTD781AXA Equitable Life Insurance713Bankers Life & Casualty Co704Black Lung Medical Benefits803Blue Cross Medigap (out of state)249Blue Cross of Northeastern PA203Blue Cross Out-of-State299Blue Shield Medigap (out of state)349Blue Shield Medigap Security 65340Blue Shield Out-of-State399Bravo Health Pennsylvania (Medicare Advantage)516Capital Blue Cross202Capital Blue Cross SecureChoice (PCO)002Capital SeniorBlue (Medicare Advantage)502Care Improvement Plus (Medicare Advantage)533Caremark749Champus (Tricare & United Concordia)400Champus/VA401CIGNA708July 2015Page 19
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier NameCarrier CodeCIGNA Medicare Access (Medicare Advantage)542Citrus Health Care (Medicare Advantage)529Combined Insurance Company of America707Commercial Insurance (Carrier name not on list)799Commercial Medigap Ins. (Not otherwise listed)740Compensation802CONSECO706Continental Casualty Ins Co710Coventry Healthcare (Medicare Advantage)527Delta Dental of PA700Eastern Life & Health Insurance Co712Employers Health Insurance Co736Equitable Assurance Soc-US713Express Scripts743First Priority Health760Freedom Blue (Medicare Advantage)501Gateway Health Plan Medicare Assured (Medicare Advantage)506Gateway Healthplus (PCO)003Geisinger Health Plan755July 2015Page 20
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier NameCarrier CodeGeisinger Health Plan (Medicare Advantage)511Geisinger Healthy Connect (PCO)004GHI Medicare Choice (Medicare Advantage)530Health Partners Essential (PCO)005Health Partners Medicare545Health Plans of PA779HealthAmerica Advantra/Advantra Gold/Advantra Silver (MedicareAdvantage)509HealthAmerica/Health Assurance757Healthfirst Medicare Plan (Medicare Advantage)522Healthguard of Lancaster759HealthMarkets Care Assured (Medicare Advantage)539Healthnet of the Northeast766Highmark Blue Cross/Blue Shield201Highmark Service Company244HIP Health Plan of Greater New York (Medicare Advantage)537HIP Health Plan of PA772Horizon BC/BS of New Jersey (Medicare Advantage)521Humana (Medicare Advantage)507Independence Blue Cross200July 2015Page 21
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier NameCarrier CodeInter-County Hosp Plan714Inter-County Phys Serv Plan715Jefferson-Pilot Life Ins Co737John Hancock Mutual Life Ins Co716Keystone 65 Complete (Medicare Advantage)514Keystone Connect (PCO)006Keystone Health Plan Central761Keystone Health Plan East762Keystone Health Plan West763Keystone SeniorBlue (Medicare Advantage)519Keystone VIP Choice544Life Insurance Co North America718Lincoln National Life Ins Co719Long Term Care Patient Pay902MD MedicareChoice (Medicare Advantage)538Massachusetts Mutual Life Ins Co720Medicare A600Medicare B100Mutual of Omaha Ins Co722July 2015Page 22
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier NameCarrier CodeNational Association of Letter Carriers731National Pharmaceutical Svc745National Vision Administrators742New York Life Insurance Co724Optimum Choice Inc of PA775Other HMO(Must enter name/address)798Paid Prescription (Medco)733PCS747PEBTF(Major Med /Medigap)744Pennsylvania Blue Shield (associated with a Blue Cross Plan)300People Benefit Life Insurance Company723Personal Choice 65/Keystone 65 (Medicare Advantage)500Philadelphia American Life Ins738Philcare Health Systems776Phoenix Mutual Life Ins Co726Physicians Care HMO784Principal Health Care of PA780Protective Life Ins Co739Provident Life & Accident Ins727July 2015Page 23
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier NameCarrier CodePrudential Health Care Plan765Prudential Ins Co of America728Qualmed Plans for Health783Security 65 Capital Plan242Security 65 Highmark Plan241Security 65 Independence Plan240Security 65 Northeast Plan243Security Blue (Medicare Advantage)504Senior Partners (Medicare Advantage)503Sterling Option 1 (Medicare Advantage)510Today’s Option (Medicare Advantage)517Transamerica Occidental Ins Co725Travelers Insurance730Tricare400UniCare (Medicare Advantage)531Unison Advantage (Medicare Advantage)513United Concordia705United Health Care721UnitedHealthcare Community Plan for Adults (PCO)007July 2015Page 24
Pennsylvania PROMISe – 820 Premium Payment Companion GuideCarrier NameCarrier CodeUnited HealthCare (Evercare/Erickson Advantage) (MedicareAdvantage)518Universal American (Medicare Advantage)543Universal Health Care (Medicare Advantage)528UPMC for Best Health (PCO)008UPMC For Life (Medicare Advantage)515UPMC Health Plan774USACare (Medicare Advantage)536Washington National Ins Co732WellCare (Medicare Advantage)520July 2015Page 25
506 Gateway Health Plan Medicare Assured (Medicare Advantage) 600 Grant Street, 41st Floor Pittsburgh, PA 15219 507 Humana (Medicare Advantage) 101 East Main Street Louisville, KY 40202 509 Advantra (Medicare Advantage) 11 Stanwix Street, Suite 2300 Pittsburgh, PA 15222 510 Sterling Option 1 (Medicare .
