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Pennsylvania PROMISeCompanion Guide837 DentalVersion 5010August 2016, Version 1.11
Pennsylvania PROMISe – 837 Health Care Claim: DentalCopyright 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.August 2016
Pennsylvania PROMISe – 837 Health Care Claim: DentalRevision HistoryDocumentVersion NumberVersion 1.1Version 1.2Version 1.3Version 1.4Version 19/12Version 1012/07/1201/09/1312/24/1309/12/14Version 1.1108/11/16August 2016Reason for RevisionsRevisions Completed ByNew documentLoop updateCorrection of dataAdded PH/95 informationUpdated Carrier List inAppendix ARemoved PH/95 from CarrierList in Appendix ARemoved namesUpdated Appendix AUpdated Appendix AUpdated Appendix A andadded Copyright Notice andDisclaimer pageUpdated logo, name, andhyperlinks from DPW toDHS; Updated Appendix A,Updated name from HP ion tationTeamTeamTeamTeamDocumentation Team
Pennsylvania PROMISe – 837 Health Care Claim: DentalTableofContentsOverview. 2Companion Guide Instructions . 3Revisions to the Companion Guide . 4Pennsylvania General HIPAA Data Elements. 5Pennsylvania Specific HIPAA Data Elements . 8Appendix A – Insurance Carriers . 9August 2016Page 1
Pennsylvania PROMISe – 837 Health Care Claim: DentalOverviewThe 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 effective January1, 2012.This Companion Guide contains detailed instructions for interpreting the ASC X12 005010X224Dental 837 transaction records for all of the different types of services that can be submitted toPROMISe in the 837 Dental format. Please disregard any instructions that do not pertain tothe services for which you are submitting.Submitters (individual providers, billing services, software vendors, and managed careorganizations) must complete a certification process in order to submit transactions to PROMISe for production processing. The certification process consists of the submission of test claims toverify that all transactions are HIPAA compliant and conform to PROMISe . To initiate thecertification process, see the certification registration process on the DHS web site tion/index.htm or contact the Hewlett PackardEnterprise Provider Assistance Center at 800-248-2152.August 2016Page 2
Pennsylvania PROMISe – 837 Health Care Claim: DentalCompanionGuideInstructionsOne of the new terms born out of HIPAA is payer variability. As each payer works to make itssystem HIPAA-compliant, there is a realization and an allowance that payers require informationand values/formats specific to their systems. As such, each payer requires that transactions becompleted with specific data. This Companion Guide was developed to communicate thePennsylvania Medical Assistance-specific information required to successfully submit the 837Dental transaction.This Companion Guide is to be used in conjunction with the ASC X12 Implementation Guidefound at http://store.x12.org. The ASC X12 Implementation Guide is the main source ofinformation 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 X12 ImplementationGuide, but are required for processing Pennsylvania Department of Human Servicestransactions; and Clarification for certain, less obvious, but still standard, uses of the transaction.August 2016Page 3
Pennsylvania PROMISe 837 Health Care Claim: DentalRevisions to theCompanion GuideTo aid the provider community in organizing these Companion Guides and the revisions that mayoccur, this document will have a revision schedule and notification process.The initial release of this Companion Guide is June 2010. The first release reflects all the knowninformation as of this date. However, as the implementation phases of PROMISe progress,updates and releases of new information may be forthcoming.Revision Process:For each new release of this Companion Guide, the information that has been changed since theprevious version will be located in this section of the guide. If a revision is made to a data element,it will be detailed in the Revision(s) Description section in the table containing the element. DHSwill clearly define the change that was made so it can be integrated into your process.Updated releases of the Transaction Guide will be posted on the DHS website. You areencouraged to check this site regularly.August 2016Page 4
Pennsylvania PROMISe 837 Health Care Claim: DentalPennsylvaniaGeneral HIPAAData ElementsManaged CareEncounter DataThe managed care organization (MCO) will be treated as aprevious payer and as the submitter. The MCO identifies the transaction as an encounter byreporting ‘RP’ (Reporting) in BHT06 (Transaction TypeCode).The MCO identifies themselves as the submitter byputting their PROMISe MPI Number and ServiceLocation Code into Loop 1000A, Data Element NM109(Submitter Primary Identifier).The MCO identifies themselves as a previous payer byputting their payer information in Loops 2320 and2330B.The MCO identifies their adjudication information byusing Loops 2320 and 2430. Pennsylvania PROMISe is expecting the value ‘HM’ in Loop 2320, Data ElementSBR09 (Claim Filing Indicator) when the payer is anMCO.The MCO must send their MCO-specific internal controlnumber in Loop 2330B, Segment REF (Other PayerClaim Control Number), using REF01 ’F8’ as thequalifier.Loop 2300, Segment CLM, Data Element CLM01 must alsocontain the MCO’s internal control number (ICN). The numberthat the MCO transmits in this position is echoed back in the277 Claim Status Response, Detail Level; Loop 2200D (ClaimSubmitter’s Trace Number). TRN02 will be set to the PatientAccount Number submitted on the original claim in Loop 2300,Segment CLM, and Data Element CLM01. August 2016The MCO reports sub-capitation arrangements by usingthe Contract Information segment (CN1) in Loop 2300.Page 5
Pennsylvania PROMISe Claims With PriorAuthorizationClaims WithAttachmentsEPSDT ClaimsGeneral ClaimClaims ReportingPrimary Codes withRelated AdditionalCodesAugust 2016837 Health Care Claim: DentalThe MCO must report a claim adjudication date in the2330B Loop, DTP segment, even when service lineadjudication dates are reported in Loop 2430 at theservice line level. If there are multiple adjudication datesat the service line level the most recent adjudicationdate at the service line level should be reported in Loop2330B.When required, the submitter must submit the priorauthorization number in Loop 2300, Segment REF (PriorAuthorization) and follow the ASC X12 Implementation Guiderules for submitting prior authorization numbers. When required, the submitter must obtain an attachmentcontrol number (ACN) from the PA PROMISe Web siteat https://promise.dhs.state.pa.us/ and submit it in Loop2300, Segment PWK (Claim Supplemental Information),following the ASC X12 Implementation Guide rules forsubmitting attachments. The Batch Cover form with the ACN must be present onall paper attachments. The ACN on the paperattachments must match the ACN entered on the relatedclaim. The Batch Cover form and paper attachmentsare submitted to DHS and must be received within 14days of the claim submission date, otherwise the claimwill reject. The submitter must supply the appropriate EPSDTcodes in Loop 2300 Segment NTE (Claim Note).Pennsylvania PROMISe will capture any of the Loops andSegments that are included in the ASC X12 ImplementationGuide and are sent in the transaction. Where not specificallymentioned in this Companion Guide, the Loops, Segments,and Data Elements must be used in accordance with theImplementation Guide. The claim must pass ASC X12Compliance edits before it can be processed in PROMISe . The submitter must supply the primary code and theadditional related (add-on) code(s) on the same claim inloop 2400 Segment SV3 The primary code must appear on the claim firstpreceding the add-on code(s)Page 6
Pennsylvania PROMISe August 2016837 Health Care Claim: DentalPage 7
Pennsylvania PROMISe – 837 Health Care Claim: DentalPennsylvaniaSpecific HIPAAData ElementsPagePROMISe Specific InstructionsField NameC.3ISA06: Interchange Sender IDUse your assigned BBS IDC.3ISA08: Interchange Receiver IDProduction - 345529167Testing - 445314156C.7GS03: Application Receiver's CodeProduction - use "345529167"Testing - use "445314156"66BHT06: Claim or EncounterIndicatorUse "CH" for Claims or "RP" for Encounters74NM103: Receiver NameUse "Department of Human Services"74NM109: Receiver Primary IdentifierUse "236003113"111SBR04: Subscriber Group NamePROMISe processes with the following codes torepresent: “WM” for women’s medical services and noninvasive contraceptive supplies“BC” for breast cancer screenings“FP” for all other Title XX services"111SBR09: Claim Filing Indicator Code" PROMISe uses the values of "MC" for Medicaid, TV"for Title V, "OF" for Title XX124NM103: Payer NameUse "Department of Human Services"124NM109: Payer IdentifierUse "236003113"127N401: Payer City NameUse "Harrisburg"127N402: Payer State CodeUse "PA"127N403: Payer Postal Zone or ZIPCodeUse "171069022"135PAT01: Individual RelationshipCodePROMISe processes with value "19" to identifynewborns179NTE01: Note Reference CodePROMISe stores when qualifier "ADD"221Loop 2320: Other SubscriberInformationPROMISe processes MCO transactions when the MCOidentifies themselves as a previous payer using the claimfiling indicator ‘HM’.246NM109: Other Payer PrimaryIdentifierPROMISe processes with the carrier codes defined inAppendix A of this documentAugust 2016Page 8
Pennsylvania PROMISe – 837 Health Care Claim: DentalAppendix A – Insurance CarriersInsurance Listings with Addresses:Carrier CodeCarrier NameAddress100Medicare Part B103Medicare Part D200Independence Blue Cross1901 Market StreetPhiladelphia, PA 19103201Highmark Blue Cross/BlueShieldFifth Avenue Place120 Fifth Avenue/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 15222August 2016Page 9
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier NameAddress249Blue Cross Medigap (out-ofstate)299Blue Cross Out of State300Highmark 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 17106400TRICARE (FormerlyChampus)Palmetto GBABox 7011Camden, SC 29020400TRICARE/Express ScriptsPO Box 390007Bloomington, MN 55439401ChampVAPO Box 65023Denver, CO 80206-9023500Personal Choice65/Keystone 65 (MedicareAdvantage)1901 Market StreetPhiladelphia, PA 19103501Highmark Freedom Blue(Medicare Advantage)120 Fifth Avenue, Suite P5501Pittsburgh, PA 15222502Capital SeniorBlue(Medicare Advantage)2500 Elmerton AvenueHarrisburg, PA 17177August 2016POPage 10
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier NameAddress504SecurityBlue (MedicareAdvantage)120 Fifth Avenue, Suite P5501Pittsburgh, PA 15222505Aetna (MedicareAdvantage)151 Farmington AvenueHartford, CT 06156506Gateway Health Plan600 Grant Street, 41st FloorMedicare Assured (Medicare Pittsburgh, PA 15219Advantage)507Humana (MedicareAdvantage)101 East Main StreetLouisville, KY 40202509Advantra (MedicareAdvantage)11 Stanwix Street, Suite 2300Pittsburgh, PA 15222510Sterling Option 1 (MedicareAdvantage)2219 Rimland DrPO Box 5348Bellingham, WA 98226511Geisinger Health Plan(Medicare Advantage)100 North Academy AvenueDanville, PA 17822512AmeriHealth 65 (MedicareAdvantage)1901 Market StreetPhiladelphia, PA 19103514Keystone 65 Complete(Medicare Advantage)1901 Market StreetPhiladelphia, PA 19103515UPMC For Life (MedicareAdvantage)112 Washington PlacePittsburgh, PA 15219516CIGNA HealthSpring(formerly Bravo Health)(Medicare Advantage)3601 O’Donnell StreetBaltimore, MD 21224517Today’s Options (MedicareAdvantage)4888 Loop Central Dr, Suite 900Houston, TX 77081August 2016Page 11
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier NameAddress518United 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)100 Central Avenue, Suite 200Saint Petersburg, FL 33701529Citrus Health Care(Medicare Advantage)5420 Bay Center Dr, Suite 250Tampa, FL 33609530GHI Medicare Choice(Medicare Advantage)441 Ninth AvenueNew York, NY 10001531UniCare (MedicareAdvantage)PO Box 9154Oxnard, CA 93031532Anthem Blue Cross/BlueShield (MedicareAdvantage)4241 Irwin Simpson Road,OHO205-A037Mason, OH 45040533Care Improvement Plus(Medicare Advantage)250 West Pratt Street, Suite 230Baltimore, MD 21201August 2016Page 12
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier NameAddress536USACare (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)P.O. Box 307Houston, TX 77274544Keystone VIP ChoicePO Box 307Linthicum, MD 21090-0307545Health Partners Medicare901 Market Street, Suite 500Philadelphia, PA 19107598Unlisted MedicareAdvantage HMO’s600Medicare Part A700Delta Dental of PA701Amalgamated Life Insurance 730 BroadwayCo.New York, NY 10003-9511703Allstate Insurance Co.August 2016One Delta DriveMechanicsburg, PA 1705560 Allstate Plaza S.Northbrook, IL 60062Page 13
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier NameAddress704Bankers 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 60025708CIGNAP.O. Box 182223Chattanooga, TX 37422709ArgusPO 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 19044715Inter-Co. Phys. Service Plan 720 Blair Mill RoadHorsham, PA 19044716John Hancock Mutual LifeInsurance Co.August 2016PO Box 111Boston, MA 02117Page 14
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier NameAddress718Life Insurance Co. NorthAmerica1601 Chestnut StreetPhiladelphia, PA 19192719Lincoln Financial Group8801 Indian Hills DriveOmaha, NE 68114720Mass Mutual Life InsuranceCo.1295 State StreetSpringfield, MA 01111721United HealthcareP O Box 740800Atlanta, GA 30374722Mutual of Omaha InsuranceCo.Mutual Of Omaha PlazaOmaha, NE 68175723People Benefit LifeInsurance Co.Claims DepartmentValley Forge, PA 19493724New 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 07102730Travelers InsuranceOne Town Square MPBHartford, CT 06183731National Association ofLetter Carriers20547 Waverly CourtAshburn, VA 20149August 2016Page 15
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier NameAddress732Washington NationalInsurance Co.PO Box 2004Carmel, IN 46032-3004733Express Scripts/Medco100 Parsons Pond DriveFranklin Lake, NJ 07417734American 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 77210-4884739Protective Life InsuranceCo.2801 HWY 280 SouthBirmingham, AL 35223740Commercial Medigap741AARP MedigapPO Box 740819Atlanta, GA 30374-0819742National VisionAdministratorsPO Box 1981East Hanover, NJ 07936-0981743Express Scripts(use carrier 733)Will be termed in the future: pleaseuse carrier 733744PEBTF150 S. 43rd Street, Suite 1Harrisburg, PA 17111-5700August 2016Page 16
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier NameAddress745National PharmaceuticalServicesPO Box 407Boystown, NE 68010747PCS950 E. Shea BoulevardScottsdale, AZ 85260749CaremarkPO Box 686005San Antonio, TX 78268-6005750Aetna HMO Health PLSEast/Central PA151 Farmington AvenueHartford, CT 06156752Alliance Health Network1700 Peach StreetErie, PA 16501753Advantage Health Plan PA121 Seventh StreetPittsburgh, PA 15222-3408755Geisinger Health PlanPO Box 8200Danville, PA 17821-8200757HealthAmerica /HealthAssuranceP.O. Box 7088London, KY 40742760First 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 WestPO Box 898819Camp Hill, PA 17089765Prudential Health Care Plan PO Box 901Horsham, PA 19044August 2016Page 17
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier NameAddress766Healthnet of the NortheastPO Box 14700Lexington, KY 40512772HIP Health Plan of PA6 Neshaminy InterplexTrevose, PA 19053774UPMC Health Plan IncPO Box 2999Pittsburgh, PA 15230775Optimum Choice Inc of PAPO Box 930Frederick, MD 21705776Philcare Health Systems2005 Market StreetPhiladelphia, PA 19103778AmeriHealth 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)802Workers’ CompensationAugust 2016Page 18
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier CodeCarrier Name803Black Lung Medical Benefits900Patient Pay902LTC Patient Pay903Transfer PenaltyAugust 2016AddressPage 19
Pennsylvania PROMISe – 837 Health Care Claim: DentalAlphabetical Listing of Insurance Carriers:Carrier NameCarrier CodeAARP Medigap741Accordia National735Advantage Health Plan753Advantra (Medicare Advantage)509Aetna (Medicare Advantage)505Aetna750Alliance Health Network752Allstate Insurance Company703Amalgamated Life Insurance Co701American General Ins Co711American Postal Workers Union734AmeriHealth HMO778AmeriHealth 65 (Medicare Advantage)512Anthem Blue Cross/Blue Shield (Medicare Advantage)532Argus709Avalon Health LTD781AXA Equitable Life Insurance713Bankers Life & Casualty Co704Black Lung Medical Benefits803August 2016Page 20
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier NameCarrier CodeBlue 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-State399Capital Blue Cross202Capital SeniorBlue (Medicare Advantage)502Care Improvement Plus (Medicare Advantage)533Caremark749Champus (Tricare & United Concordia)400Champus/VA401CIGNA708CIGNA HealthSpring (formerly Bravo Health) (Medicare Advantage) 516CIGNA 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)740August 2016Page 21
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier NameCarrier CodeCONSECO706Continental Casualty Ins Co710Coventry Healthcare (Medicare Advantage)527Delta Dental of PA700Eastern Life & Health Insurance Co712Employers Health Insurance Co736Express Scripts/Medco733Express Scripts (use 733) (will be termed in the future)743First Priority Health760Gateway Health Plan Medicare Assured (Medicare Advantage)506Geisinger Health Plan755Geisinger Health Plan (Medicare Advantage)511GHI Medicare Choice (Medicare Advantage)530Health Partners Medicare (Medicare Advantage)545Health Plans of PA779HealthAmerica/Health Assurance757Healthfirst Medicare Plan (Medicare Advantage)522HealthMarkets Care Assured (Medicare Advantage)539Healthnet of the Northeast766August 2016Page 22
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier NameCarrier CodeHighmark Blue Cross/Blue Shield201Highmark Blue Shield300Highmark Feedom Blue (Medicare Advantage)501Highmark 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 Cross200Inter-County Hosp Plan714Inter-County Phys Serv Plan715Jefferson-Pilot Life Ins Co737John Hancock Mutual Life Ins Co716Keystone 65 Complete (Medicare Advantage)514Keystone Health Plan Central761Keystone Health Plan East762Keystone Health Plan West763Keystone SeniorBlue (Medicare Advantage)519Keystone VIP Choice (Medicare Advantage)544August 2016Page 23
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier NameCarrier CodeLife 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 Co722National Association of Letter Carriers731National Pharmaceutical Svc745National Vision Administrators742New York Life Insurance Co724Optimum Choice Inc of PA775Other HMO(Must enter name/address)798Patient Pay900PCS747PEBTF(Major Med /Medigap)744People Benefit Life Insurance Company723Personal Choice 65/Keystone 65 (Medicare Advantage)500August 2016Page 24
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier NameCarrier CodePhiladelphia American Life Ins738Philcare Health Systems776Phoenix Mutual Life Ins Co726Physicians Care HMO784Principal Health Care of PA780Protective Life Ins Co739Provident Life & Accident Ins727Prudential 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)504Sterling Option 1 (Medicare Advantage)510Today’s Option (Medicare Advantage)517Transamerica Occidental Ins Co725Transfer Penalty903August 2016Page 25
Pennsylvania PROMISe – 837 Health Care Claim: DentalCarrier NameCarrier CodeTravelers Insurance730Tricare400UniCare (Medicare Advantage)531Unison Advantage (Medicare Advantage)513United Concordia705United Health Care721United HealthCare Companies (Medicare Advantage)518Universal American (Medicare Advantage)543Universal Health Care (Medicare Advantage)528UPMC For Life (Medicare Advantage)515UPMC Health Plan774USACare (Medicare Advantage)536Washington National Ins Co732WellCare (Medicare Advantage)520Workers Compensation802August 2016Page 26
Pennsylvania PROMISe 837 Health Care Claim: Dental August 2016 Page 4 Revisions to the Companion Guide To aid the provider community in organizing these Companion Guides and the revisions that may occur, this document will have a revision schedule and notification process. The initial release of this Companion Guide is June 2010.
