Pictionary rsvd 2015.doc 10.11.17 - rowan.edu · Pictionary and the insurance company product...

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2013 Rowan University School of Osteopathic Medicine Information Resources and Technology Clinical Systems Department

Centricity Business-Version 2.2

09/2017

Insurance Cards

Centricity Business/IDX

This document is available on the Clinical Applications website

http://rowan.edu/som/ist/physiciansys.html

[email protected]

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09/2017

INTRODUCTION

The Clinical Applications Department has developed the Insurance Pictionary as a reference guide for users when entering insurance information in Centricity Business/IDX. This information will be updated periodically. The insurance products are listed alphabetically. Each card will list the corresponding CB/IDX-FSC and FSC-Mnemonic. The Table of Contents will list the page numbers detailing how to use the Pictionary and the insurance company product names. In an effort to maintain the most relevant insurance card copies within the training documentation, we request the following (should you receive an insurance card that has not been incorporated and/or a newer version): EMR Users

The insurance card should be scanned into the EMR

Document Type: Internal Other

Create Helpdesk Ticket via email to Centricity Business (IDX) email [email protected]

Include: Patient’s Name, Date of Birth (DOB), and Medical Record Number (MRN) Non-EMR Users

Copy the insurance card

Create electronic version (scan to your RowanSOM email address)

Create Helpdesk Ticket via email to Centricity Business (IDX) email [email protected]

Attach Electronic version of the insurance card

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09/2017

TABLE OF CONTENTS

INTRODUCTION ............................................................................................................................... 2

AARP .................................................................................................................................................... 7

AETNA COMMERCIAL/PPO/POS……………………………………………………………….8

AETNA HMO ………………………………………………………………………………………..9

AETNA TPA ………………………………………………………………………………………..10

AETNA MEDICARE ………………………………………………………………………………11

AETNA - (SUMMARY PAGE) ................................................................................................. …. 12

UNITED HEALTHCARE COMMUNITY PLAN (FORMERLY AMERICHOICE PA HMO) ............................................................................................................................................................. 13

AMERIHEALTH ADMINISTRATORS ........................................................................................ 14

AMERIHEALTH HMO/POS OF NEW JERSEY ........................................................................ 15

AMERIHEALTH PPO OF NEW JERSEY ................................................................................... 16

AMERIHEALTH COMMUNITY ADVANTAGE ........................................................................ 17

(FORMERLY AMERIHEALTH VALUE NETWORK) .................................................................. 18

AMERIHEALTH - (SUMMARY PAGE) ...................................................................................... 19

AMERIGROUP – MEDICAL ASSISTANCE ............................................................................... 20

BC/BS OVERVIEW…………………………………………………………………………….21-22

BC/BS FEDERAL BLUE CROSS BLUE SHIELD ....................................................................... 23

BC/BS HORIZON (TRADITIONAL) ............................................................................................ 24

BC/BS HORIZON (NATIONAL) .................................................................................................... 25

BC/BS HORIZON (EPO) ................................................................................................................. 26

BC/BS HORIZON BLUE CHOICE ………………………………………………………………27

BC/BS HORIZON (HMO & MEDICARE BLUE) ........................................................................ 28

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BC/BS HORIZON NJ HEALTH NJMA …………………………………………………………29

HORIZON NJ TOTAL CARE PROVIDER QUICK REFERENCE GUIDE……………..30-35

BC/BS HORIZON - (SUMMARY PAGE) ..................................................................................... 36

HORIZON BC/BS ………………………………………………………………………………37-38

BC/BS IBC/PA BS SECONDARY .................................................................................................. 39

BC/BS IBC/PA BS 65 SPECIAL & SECURITY 65 ...................................................................... 40

BC/BS IBC/PERSONAL CHOICE 65 ............................................................................................ 41

BC/BS IBC PLANS SUMMARY PAGE …………………………………………………………42

CIGNA PLANS ................................................................................................................................. 43

COMMERCIAL INSURANCE ....................................................................................................... 44

DEVON .............................................................................................................................................. 45

HEALTHNET ................................................................................................................................... 46

INTERGROUP/BEECHSTREET ………………………………………………………………..47

KEYSTONE HMO/KEYSTONE 65 ............................................................................................... 48

INDEPENDENCE BC/BS ……………………………………………………………..............49-50

(MA) NEW JERSEY MEDICAL ASSISTANCE (NJMA) .......................................................... 51

(MA) MEDICAL ASSISTANCE (SUMMARY PAGE) ............................................................... 52

MAGACARE ……………………………………………………………........................................53

MAGELLAN BEHAVIORAL HEALTH ....................................................................................... 54

MEDICARE/RAILROAD MEDICARE ........................................................................................ 55

MEDICARE REPLACEMENT PLANS (SUMMARY PAGE) ................................................... 56

MULTIPLAN .................................................................................................................................... 57

OXFORD ........................................................................................................................................... 58

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PREFERRED HEALTH NETWORK (MAX) ............................................................................... 59

QUALCARE ...................................................................................................................................... 60

THIRD PARTY ADMINISTRATORS (TPA) ............................................................................... 61

CHAMPUS (TRICARE) .................................................................................................................. 62

UNION INSURANCE (LOCAL UNIONS) .................................................................................... 63

UNITED BEHAVIORAL HEALTH ……………………………………………………………..64

UNITED HEALTHCARE/GOLDEN RULE ……………………………………………………65

UNITED HEALTHCARE GROUP - (SUMMARY PAGE) ......................................................... 66

US FAMILY HEALTH PLAN ........................................................................................................ 67

VALUE OPTIONS BEHAVIORAL HEALTH ............................................................................. 68

VETERANS ADMINISTRATION ................................................................................................. 69

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HOW TO USE THE PICTIONARY

The pictionary is intended to aid in the selection of the correct Financial Status Classification (FSC) in CB/IDX. If you are not able to find the assistance you need in this document, you may send an email to [email protected] for assistance. Copies of insurance cards have been scanned into this document and sorted in alphabetical order by insurance company name at the beginning of the section for each carrier included in the pictionary. Whenever possible, this document will give the user general information about the insurance carrier and the types of plans offered by that carrier. Cards will be presented in alphabetical order and then sorted by plan type (HMO, PPO, Indemnity/Commercial) when appropriate. Every effort has been made to include sample cards from as many carriers as possible. However, not every insurance plan available to the public or sample card for every carrier plan could be included. Search alphabetically to find the page or section of this document containing copies of the insurance cards for the insurance company that issued the patient’s policy. Please locate the copy of the card or the most similar to the card presented by the patient when applicable. The IDX-FSC and FSC-Mnemonic will be displayed for use when entering the patient’s insurance information within the various systems. Please read all sides of the card or call the carrier to obtain the correct address for claims submission. RowanSOM Implemented the Eligibility Module in November 2013; as a result, a column has been added indicating if the insurance is, Eligibility enabled Yes/No (Y/N). IDX Users When applicable users must search and select the insurance company address from the insurance dictionary to ensure timely electronic filing.

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AARP

AARP - Medigap Coverage (patient pays for coverage): If a Medicare patient has supplemental insurance that is not offered by a former employer to help cover non-reimbursable charges, deductibles, and co-insurance, this insurance is called medigap. AARP - Primary Insurance Plans (Benefit Alert) AARP primary coverage plans provide limited benefits.

PLAN DESCRIPTION FSC # FSC

Mnemonic Eligibility Enabled

AARP (after Medicare) 50 CIM Y

AARP (Primary Coverage)-Commercial Insurance 41 CI Y

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AETNA COMMERCIAL/PPO/POS

FSC 40

FSC 48 FSC 40


Mnemonic EligibilityEnabled

AETNA COMMERCIAL (INDEMNITY, CHOICE POS, PPO)

40 AHP Y

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AETNA HMO

FSC 48



AETNA HMO 48 USH Y

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AETNA TPA

Government Employees (GEHA) 462

Aetna Signature Administrators (TPA). Third Party Administrator (TPA): Third Party Administrators serve as PPO Networks. TPAs provide administrative services to small employer groups and/or self funded Health Organizations; they re-price the claims to ensure the best payment rate. Benefit limitations may apply.



AETNA TPA (Aetna Signature Administrators) 462 ATPA N

Member Name: Participant, John Identification#: Varies per Employer Phone Number: Review Insurance Card Claims Address: Review Insurance Card

Employer’s Logo

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AETNA MEDICARE

FSC 848 FSC 840

Note: Aetna Medicare plan will always have an ID number that starts with “ME” followed by a number.



AETNA GOLDEN MEDICARE (HMO) 848 AEMA Y

AETNA MEDICARE ADVANTAGE (PPO) 840 AEMP Y

AETNA MEDICARE PRIME (NON-PAR) 888 MRA N

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AETNA - (SUMMARY PAGE)



AETNA HMO – POS 48 USH Y

AETNA Commercial-INDEMNITY, PPO, EPO (i.e. Non HMO) 40 AHP Y

AETNA MEDICARE (HMO) 848 AEMA Y

AETNA ADVANTAGE (PPO) 840 AEMP Y

AETNA MEDICARE PRIME (NON-PAR) 888 MRA N

AETNA TPA (Aetna Signature Administrators) 462 ATPA N

AETNA BETTER HEALTH – Medicaid 41 CI N

AETNA BEHAVORIAL HEALTH – RowanSOM GRP#3 375 AEB N

AETNA BEHAVORIAL HEALTH – RowanSOM GRP#4 675 ABH N

AETNA BEHAVORIAL HEALTH – RowanSOM GRP#7 775 AEBH N

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UNITED HEALTHCARE COMMUNITY PLAN (FORMERLY AMERICHOICE PA HMO)

United Community Plan Behavioral Health is provided by Optum for developmental disabilities and long term care. Rowan is currently non-participating with Optum. All other behavioral health services are to be processed by NJMA.

PLAN DESCRIPTION FSC # FSC Mnemonic EligibilityEnabled

UNITED HEALTHCARE COMMUNITY PLAN (formerly Americhoice of New Jersey) 451 ACNJ Y

UNITED HEALTHCARE COMMUNITY PLAN 2NDRY (formerly Americhoice of New Jersey)

207 AC2 Y

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AMERIHEALTH ADMINISTRATORS

.



AMERIHEALTH ADMINISTRATORS INDEPENDENCE ADMINISTRATORS

435 AMA Y

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AMERIHEALTH HMO/POS OF NEW JERSEY



AMERIHEALTH HMO 77 DVH Y

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AMERIHEALTH PPO OF NEW JERSEY



AMERIHEALTH PERSONAL CHOICE PPO 161 PC Y

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AMERIHEALTH COMMUNITY ADVANTAGE (FORMERLY AMERIHEALTH VALUE NETWORK)

Note: CB/IDX System re-labeling of this FSC will occur during the Fiscal Year End process July 2014.



AMERIHEALTH COMMUNITY ADVANTAGE Formerly Amerihealth Value Network (Cooper Advantage or Tier 1 and Tier 2 Advantage) EPO

461 AVN Y

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AMERIHEALTH - (SUMMARY PAGE)



AMERIHEALTH HMO/POS 77 DVH Y

AMERIHEALTH PERSONAL CHOICE PPO 161 PC Y

AMERIHEALTH ADMINISTRATORS 435 AMA Y

AMERIHEALTH MEDIGAP (Secondary to Medicare) 30 P65 Y AMERIHEALTH COMMUNITY ADVANTAGE Formerly Amerihealth Value Network (Cooper Advantage or Tier 1 and Tier 2 Advantage)

461 AVN Y

AMERIHEALTH HMO/POS EXPIRED 80 DVE N

AMERIHEALTH PERSONAL CHOICE PPO EXPIRED 341 PCE N

AMERIHEALTH ADMINISTRATORS EXPIRED 436 AME N

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*Q1B – Has been assigned to multiple product lines. Users must review the plan type rendered on the electronic validation tool to ensure the correct FSC

has been utilized. Additionally, patients presenting for service with the EPO plan insurance cards will list the Community Advantage or Tier 1 Advantage logos.

Prefix/Suffix

Plan Type

IDX-FSC

FSC

Mnemonic

Telephone

Physician

Claims Address

Q1C,Q2C,Q3B,Q3C HMO 77 DVH 215-241-2400 PO Box 41574

Philadelphia, PA 19101-1574

Q1P ,Q2P, Q3A,Q3P POS 77 DVH 215-241-2400 PO Box 41574


Q1H,Q1S,Q1T,Q2B *Q1B

PPO, PPO-HSA POS-PLUS

Major-Medical 161 PC 215-241-2400

PO Box 41574 Philadelphia, PA

19101-1574

*Q1B

EPO EPO-HAS

Community Advantage Tier 1 and Tier 2

Advantage

461 AVN 215-241-2400 PO Box 41574


Q1E

Amerihealth Medigap (Secondary to Medicare)

30

P65 215-241-2400

PO Box 898845 Camp Hill, PA

17089-8845

Suffix = (TPA) PPO 436 AMA 215-241-2400 PO Box 21545

Eagan, MN 55121

Amerihealth Prefix/Suffix IDX-FCS Table

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AMERIGROUP – MEDICAL ASSISTANCE

*NON PAR FOR OFFICE APPOINTMENTS

PLAN DESCRIPTION FSC # FSC MnemonicEligibilityEnabled

AMERIGROUP 41* AMG Y

AMERIGROUP 2NDRY 209* AM2 Y

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Blue Cross/Blue Shield Overview

The Blue Cross and Blue Shield Association is the trade association for the oldest and largest group of health insurance companies in America. It is comprised of 44 independent, locally operated companies. These plans are located in 50 states, the District of Columbia, Puerto Rico and Internationally and offer a variety of insurance products to all segments of the population, including individuals, small businesses, seniors and large employer groups. The Blue Cross plan pays for hospital charges and the Blue Shield plan pays physician charges. If the patient’s insurance card only indicates Blue Cross ask them if they have any additional insurance coverage to pay for the physician services. The Alpha prefix and Blue Cross Blue Shield Plan Codes are the key elements used to identify and route the area claims. The prefix identifies the plan (by geographical area) or national account to which the member belongs. Blue Cross pays for Hospital services Blue Shield pays for Physician services You must first determine the type of Blue Cross/ Blue Shield coverage the patient has and then select the appropriate IDX-FSC(s) Participating Blue Cross/ BlueShield Plans RowanSOM participates with the following Blue Cross/ BlueShield Plans Horizon Blue Cross Blue Shield of New Jersey Plan Codes 780/280 Blue Cross Blue Shield Federal Plan The Federal Blue Cross Blue Shield Plan can be identified by the single alpha prefix character R and must be billed to the local Plan Horizon (BC/BS)

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BC/BS HORIZON BLUE CROSS BLUE SHIELD

In Mid November 2005, Horizon Blue Cross Blue Shield of New Jersey converted the Member Identification Number from the Social Security Number to a 15 character Unique Identification Number. The new Identification Number will retain the three-letter Alpha-prefix which is required to ensure smooth claim submission. As existing patients present for care with cards, upon insurance verification; certified users must update the account reflecting the new information. Users, who do not physically view cards, be sure to ask the patient to read the complete ID number or contact Horizon at 800-624-1110. The new ID format is described below.

Position 1-3: Alpha Prefix Position 4: Numeric Position 5-7: Alpha Numeric Position 8-14: Numeric Position 15: will always be zero (0)

Attached you will find the updated Horizon Alpha Prefix Grids which includes Alpha prefixes for Local Unions. Horizon Blue Cross Blue Shield of New Jersey is one of the designated insurance carriers for the Local Unions. Horizon Blue Cross Blue Shield of New Jersey members can be identified by the BC/BS Plan Codes 280/780 on their insurance identification cards. Patients presenting for service with Plan Codes 280/780 must be registered according to the attached Alpha Prefix Grid. Patients presenting with Plan Codes other than Horizon BC/BS of NJ 280/780 with the respective FSC.

Suitcase logo

The BlueCard Program links participating health care providers and the independent Blue Cross and/or Blue Shield Plans across the country and abroad with a single electronic network for claims processing and reimbursement.

Members whose ID cards display the PPO in the suitcase logo and are traveling or reside outside their Plan’s service area receive PPO-level benefits when they need services from participating physicians and other health care professionals.

Members whose ID cards display the blank suitcase logo may be enrolled in a product other than PPO.

Members whose ID cards do not display a suitcase logo are excluded from receiving benefits through the BlueCard Program.

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BC/BS FEDERAL BLUE CROSS BLUE SHIELD



Federal BC/BS (Prefix – R) 21 NJBS Y

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BC/BS HORIZON (TRADITIONAL)

* Only use FSC 54 when patient has (2) Horizon Plans. Not to be used after Medicare.



Horizon BC/BS Traditional, PPO, 21 NJBS Y

Horizon BC/BS Traditional, PPO, Secondary 54* NB2 Y

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BC/BS HORIZON (NATIONAL)



Horizon BC/BS Commercial 24 NBS Y

Horizon BC/BS Secondary 54 NB2 Y

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BC/BS HORIZON (EPO)

Horizon Advanced EPO RowanSOM has entered into an agreement with Horizon Blue Cross Blue Shield (BC/BS) regarding the Horizon Advanced EPO Plan. Patients with this product may elect to have a Primary Care Physician (PCP) coordinate their medical care. When the patient has selected a RowanSOM Provider as their PCP; services rendered will be reimbursed based on capitation rather than Fee‐For‐Service rates. Currently, the Pulmonary and Sports Medicine Groups are considered non‐participating. Users within this area will not be able to retrieve referral information. New FSCs have been instituted in conjunction with this initiative. The Alpha prefixes listed below do not constitute the entire of list of Horizon EPO prefixes. Always validate the patient’s coverage including plan type and PCP selection to ensure the appropriate FSC has been selected. Effective January 1, 2014, patients presenting with this product should be registered as described below. Users will continue to submit claims to the address listed in the insurance dictionaries.



Horizon BC/BS EPO (Non-RowawSOM PCP) 31 NJEPO Y

Horizon BC/BS EPO CAP REG (RowanSOM PCP Selection) 33 HCR Y

Alpha Prefix IDX‐FSC FSC Name

FSC Mnemonic

FSC Type

JGA, JGB, JGC, JGD, JGE, JGF, JGG, JGH, JGI, JGJ, JGL, JGM, JGR, JGS, JGV, JGW, JGX, JGY, JGZ 31 Horizon EPO NJEPO

Registration Non‐Capitated

JGV, YKH 33 Horizon EPO CAP REG HCR Registration Capitated

JGV, YKH 34 Horizon EPO CAP INV HCI Invoice

Capitated

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BC/BS Horizon Blue Choice



Horizon Blue Choice 156 BC Y

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BC/BS HORIZON (HMO & MEDICARE BLUE)



Horizon HMO BLUE 74 MGP Y

Horizon MEDICARE ADVANTANGE 874 HOMA Y Horizon NJ MEDICARE ADVANTAGE DIRECT

876 HMAP Y

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BC/BS Horizon NJ Health NJMA

* FSC 208 is only used when patient has Medicare or MRA as Primary.

Users should not enter the alpha (if any) prefix listed on the card for patients presenting with this product.



Horizon NJ Health (NJMA) Formerly Horizon Mercy 96 MHP Y

Horizon NJ Health (NJMA) 2NDRY 208* MH2 Y

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BC/BS HORIZON - (SUMMARY PAGE)

The system will not allow the second plan to be added with its assigned FSC number.

The second plan should be added using FSC 54 (NJ Blue Shield Second).

Union Employee Health coverage based on number of hours worked per month



Federal BC/BS (Prefix - R) Plan 21 NJBS Y

Horizon BC/BS Traditional, PPO, EPO Plans 21 NJBS Y

Horizon BC/BS National Plan 24 NBS Y

Horizon BC/BS EPO (Non-RowanSOM PCP) 31 NJEPO Y

Horizon BC/BS EPO CAP REG (RowanSOM PCP Selection) 33 HCR Y

Horizon Blue Choice 156 BC Y

Horizon BC/BS HMO Blue Plan 74 MGP Y

Horizon BC/BS Medicare Blue Plan (HMO) 874 HOMA Y

Horizon BC/BS (65 special & Security 65) Medigap 29 N65 Y

HORIZON MEDICARE ADVANTAGE PPO 876 HMPA Y

*Horizon BC/BS (Secondary Plans) 54 NB2 Y

NJ Carpenters’ Primary Local Prefix ZJP 21 NJBS N

NJ Teamsters’ Primary Local Prefix TWP 21 NJBS N

Horizon BC/BS Local Prefix HUF & HWX 24 NBS N

Horizon NJ Health (NJMA) Formerly Horizon Mercy Plan 96 MHP Y

Horizon NJ Health (NJMA) 2NDRY 208 MH2 Y

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Centricity Business-Version 2.2 09/2017

Prefix

Plan Type

IDX-FSC

FSC

Mnemonic

Telephone

Physician

Claims Address

YHC, YHU, YHS, YHQ NJT - NJTransit

Commercial 21 NJBS 800-624-1110 PO Box 1609 Newark, NJ 07101-1609

R, 8-Digits & PPO Logo

(Federal Employees) Commercial 21 NJBS 800-624-1110

PO Box 656 Newark, NJ 07101-1609

FMA, FMR, NCH, YHF, YHN, HIF, HSG

Commercial 21 NJBS

800-624-4758


NGM, DEH, DMM, DTM, DTP, NGM, GMM

General Motors/Delphi Auto

Commercial

24 NBS

800-452-1396 P O Box 639 Newark, NJ 07101-0637

FMA, FMR Ford Motor Company

Commercial 21 NJBS

800-624-4758

P O Box 247 Dept V.

Newark, NJ 07101-0247 ATT, AYA, LTI, AT&T

Avaya, Lucent Technology Members

Blue Choice

156

BC

800-624-1110


YHD, YHG, YHP, YHH & ALL other POS

members

Blue Choice

156

BC

800-624-1110


NJX – NJ State Health Benefit Program

Commercial 21 NJBS 800-624-1110 PO Box 820 Newark,

NJ 07101-0820

Horizon Blue Cross Blue Shield Prefix/Suffix IDX-FCS Table

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Centricity Business-Version 2.2 09/2017

Prefix

Plan Type

IDX-FSC

FSC

Mnemonic

Telephone

Physician

Claims Address

JGK, JGY, JGW,

JGX,JGZ

(EPO & EPO Plus) Non-Capitated

31 NJEPO 800-624-1110

PO Box 1609 Newark, NJ 07101-1609

JGV, YKH (EPO & EPO Plus)

Capitated 33 HCR 800-624-1110

PO Box 1609 Newark, NJ 07101-1609

NHC, HSG, HWW, HWA

Commercial 21 NJBS 800-624-1110 PO Box 1609 Newark, NJ 07101-1609

JGA, JGD, JGG, JGF

(Consumer Directed Healthcare)

21 NJBS 800-624-1110 PO Box 1609 Newark, NJ 07101-1609

Local Union TWP, ZJP

PPO 21 NJBS 800-624-1110 PO Box 1609 Newark, NJ 07101-1609

Local Union HUF, HWX

PPO

24 NBS 800-452-1396

PO Box 1301 Neptune, NJ

07754

YHM,YHO HMO 74 MGP 800-624-1110 PO Box 820 Newark, NJ 07101-0820

YHT,YKB,YKD, YKN,YHV,YKI,YKO,

YKM, YKK Medicare Advantage 874 HOMA 800-624-1110

PO Box 1609 Newark, NJ 07101-1609

YHR, YHW Medicare Supplemental 29 N65 800-624-1110

PO Box 1184 Newark, NJ 07101-1184

Horizon NJ Health (NJMA)

NJ Medical Assistance 96 MHP 877-765-4325 PO Box 7117

London, KY 40742

Horizon Blue Cross Blue Shield Prefix/Suffix IDX-FCS Table

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BC/BS IBC/PA BS SECONDARY

Used when Medicare is not the primary coverage



PA B/S 2ND 55 PB2 Y

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BC/BS IBC/PA BS 65 SPECIAL & SECURITY 65

Used when Medicare is Primary


MnemonicEligibility Enabled

PA 65 SPECIAL 30 P65 Y

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BC/BS IBC/PERSONAL CHOICE 65

PLAN DESCRIPTION FSC #FSC


PERSONAL CHOICE 65 MEDICARE ADVANTAGE 861 PCMA Y

PC65 MEDICARE ADVANTAGE EXPIRED 862 PCME N

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BC/BS IBC Plans – Summary Page

*IBC/PA BS Secondary Plans

FSC 54 – is used when Medicare is not the Primary payer.

FSC 30 – is used when Medicare is the Primary payer



PA B/S 2ND 55 PB2 Y

PERSONAL CHOICE 65 MEDICARE ADVANTAGE 861 PCMA Y

PA 65 SPECIAL 30 P65 Y

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CIGNA PLANS

There was a request to add another FSC to designate Cigna HMO vs Cigna PPO. Could this be incorporated in this document?



CIGNA 56 CIG Y CIGNA BEHAVIORAL HEALTH RowanSOM GRP#4 701 CBH N

CIGNA BEHAVIORAL HEALTH RowanSOM GRP#7 776 CIGB N

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COMMERCIAL INSURANCE

Commercial Insurance Primary is used when the insurance carrier for the primary commercial insurance coverage does not have designated FSCs.

Commercial Insurance Secondary is used if the patient has two commercial insurance

plans that do not have designated FSCs Commercial Insurance Secondary cannot be assigned before a primary insurance coverage FSC has been assigned.

Commercial Insurance After Medicare is used when the patient has Medicare primary

and secondary or supplemental coverage



COMMERCIAL-Primary 41 CI N COMM INSUR-2NDRY 44 CIS N

COM INS AFT MEDICARE 50 CIM N

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DEVON

Devon Health Care Network (TPA). Third Party Administrator (TPA): Third Party Administrators serve as PPO Networks. TPAs provide administrative services to small employer groups and/or self funded Health Organizations; they re-price the claims to ensure the best payment rate. Benefit limitations may apply.



DEVON/AMERICARE 165 AMRC N

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HEALTHNET

FSC 50 CIM PAYER ID# 06108

FSC 44 CIS

FSC 84 CI3



HEALTHNET PPO 41 HEAP N

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INTERGROUP/BEECHSTREET

InterGroup Services Corporation (TPA). Third Party Administrator (TPA): Third Party Administrators serve as PPO Networks. TPAs provide administrative services to small employer groups and/or self funded Health Organizations; they re-price the claims to ensure the best payment rate. Benefit limitations may apply.



INTERGROUP 454 ITG N

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INDEPENDENCE BC KEYSTONE HMO/KEYSTONE 65



KEYSTONE HMO 452 KHP Y KEYSTONE HP EAST EXPIRED 456 KHPE N

KEYSTONE 65 MEDICARE 852 KEMA Y

KEYSTONE 65 MCR EXPIRED 853 KMCE N

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Prefix/Suffix

Plan Type

IDX-FSC

FSC

Mnemonic

Telephone

Physician

Claims Address

QCH,QCL,YXQ YXW, YXZ

(formerly – YXH,YXE) Keystone - HMO 452 KHP 215-241-2400

PO Box 69353 Harrisburg, PA

17106-9353

QCG,QCJ,YXR (formerly – YXG,YXJ)

Keystone - POS

452 KHP 215-241-2400 PO Box 69353 Harrisburg, PA

17106-9353 CNS,DQU,DVK,EQJ,FJM

FYP,GJF,GJJ,GKV,GSN,IKE IKF,IKM,IXU,LUF,MFL,MGA

MGG,OBW,OCQ,OMJ,OPY,PBX PRP,PUQ,SNC,UJX,WUF,YXA

YXL,YXT

Independence Administrators TPA 435 AMA 215-241-2400 PO Box 21974

Eagan, MN 55121

QCI,QCK (formerly – YXC,YXI)

Keystone65 (Medicare Replacement Plan)

852 KEMA 215-241-2400


17106-9353

YXF,YXO,YXP,YXU (formerly – QCB)

Personal Choice - PPO

161 161 215-241-2400

Amerihealth Independence PO Box 69352 Harrisburg, PA

17106-9352

YXK (formerly QCM)

Personal Choice65

(Medicare Replacement Plan)

861

PCMA 215-241-2400


17106-9352 AMS,ATS,UPP,AEK,APQ,ARR ASE,AUA,AUK,BAL,BPB,BRD BWW,BYN,CBE,CDJ,CDQ,CDZ CHC,COS,CQA,CQX,CUI,CZN CZS,DAZ,DBO,DFB,DGR,DKVDPO,DVU,DWU,EEN,EGD,EIZ FFI,FQU,FSC,GCY,GEA,GEU

Blue Card & National Plans 24 NBS 215-241-2400

Independence Blue Cross PO Box 13497

Philadelphia, PA 19101

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The Alpha prefixes listed above do not constitute the entire list of Independence BC/BS prefixes. Always validate the patient’s coverage including plan type and PCP selection to ensure the appropriate FSC has been selected. BlueCard® is a national program through the Blue Cross and Blue Shield Association (BCBSA), an association of independent Blue Cross® and Blue Shield® plans, that enables enrollees of one commercial BCBSA plan to obtain health care service benefits while traveling or living in another BCBSA plan’s service area. If a patient presents with an out of state BCBS card make sure to check if it has a suitcase on it; this means we can accept the patient.

Prefix/Suffix

Plan Type

IDX-FSC

FSC

Mnemonic

Telephone

Physician

Claims Address

HAJ,HKZ,HXT,ICC,INW,IUR IYC,KPY,KXH,LFS,LLH,LMS

LRC,LYW,MGL,MNF,NPP,NZK OCR,OCZ,PAH,PBT,PDA,PSM

PTA,PUI,PXF,RAE,RID,RJG RLA,ROO,ROQ,SDA,SEZ,SFU




SHQ,SKH,SQT,SZA,TFE,TMB TMW,TQJ,TRX,TWS,UBF,UBLU

DS,UBL,UFN,UFP,UFT,UHF ULB,UPB,URT,WHV,WIQ,WIV

WQB




QCA,QCC,QCN,QCO,QCP QCR,YXN

(formerly – QCD,QCW,QCT,YXD,YXS)

Blue Card & National Plans 24 NBS 215-241-2400 Independence Blue Cross PO Box 13497


QCE, QCR (formerly – QCS,YXS)

Security65 Medigap Plans (Secondary to Medicare)

30 P65 215-241-2400 PO Box 898845 Camp Hill, PA

17089-8845

Independence Products Prefix/Suffix IDX-FCS Table

51



09/2017

(MA) NEW JERSEY MEDICAL ASSISTANCE (NJMA) - MEDICAID

As of 06/01/06 Burlington, Camden and Gloucester Counties started a pilot program for the new State of New Jersey Health Benefits. Patients eligible for Medicaid who live in these counties will no longer receive the monthly paper card. They will receive a permanent plastic card displayed above. (As of 09/01/06, no paper cards will be issued.) The first three positions of the CCN or Control Number will always be “777”, followed by an eleven position non-intelligent enumeration, followed by a two-position issuance number of “01” to indicate this is the first HBID card. In the event the beneficiary requires a replacement card, the CCN will remain the same but the issuance number will increment to “02” indicating another card has been issued. A striking difference from the paper card is the lack of any eligibility and enrollment information on the card itself. There is no Medicaid ID and coverage period listed for the beneficiary; therefore, this card can not be used as proof of eligibility. Users are required to check validation tool for the Medicaid ID number and enrollment information. If the validation tool is unavailable, the user must call 800-676-6562 to verify eligibility. After verify eligibility users must enter the 10 digit Identification number and 2 digit person number a total of 12 characters within the identification number field.



MA NEW JERSEY 101 NJMA Y MEDICAID SECONDARY 102 WAM Y

52



09/2017

(MA) MEDICAL ASSISTANCE (SUMMARY PAGE) - MEDICAID



United Healthcare Community Plan (formerly AMERICHOICE NJ HMO) 451 ACNJ Y United Healthcare Community Plan 2ndry (formerly Americhoice NJ) 207 AC2 Y

Horizon NJ Health (formerly Horizon Mercy) 96 MHP Y

Horizon NJ Health 2ndry (after Medicare) 208 MH2 Y Amerigroup 41 AMG Y Amerigroup 2ndry 44 AM2 Y

Medicaid Secondary (formerly Welfare after Medicare) 102 WAM Y

53



09/2017

MAGNACARE



MAGNACARE 189 IOE N

54



09/2017

MAGELLAN BEHAVIORAL HEALTH

PLAN DESCRIPTION FSC #FSC


MAGELLAN MENTAL HEALTH RowanSOM GRP #7 774 MAG N

MAGELLAN NON HMO RowanSOM GRP #7 797 MNHM N

Magellan HMO Expired RowanSOM GRP #7 778 MGE N

Magellan Non-HMO Expired RowanSOM GRP #7 796 MXP N

MAGELLAN (MENTAL HEALTH) RowanSOM GRP #4 170 GSP N

MAGELLAN NON HMO RowanSOM GRP #4 197 MNH N

Magellan HMO Expired RowanSOM GRP #4 472 MEH N

Magellan Non-HMO Expired RowanSOM GRP #4 496 MEX N

MAGELLAN MENTAL HEALTH RowanSOM GRP #3 370 MMH N

MAGELLAN NON HMO RowanSOM GRP #3 397 MNO N

Magellan HMO Expired RowanSOM GRP #3 372 MHE N

Magellan Non-HMO Expired RowanSOM GRP #3 396 MNE N

55



09/2017

MEDICARE/RAILROAD MEDICARE



Medicare Traditional 81 M Y

Medicare Travelers (Railroad) 88 MEDT Y

Medicare Traditional 2NDRY 86 MSEC Y

56



09/2017

MEDICARE REPLACEMENT PLANS (SUMMARY PAGE)



AETNA Medicare HMO 848 AEMA Y

AETNA Medicare Advantage PPO 840 AEMP Y

CIGNA HEALTHSPRING (formerly BRAVO HEALTH) * 851 BRMA Y

Horizon Medicare Advantage 874 HOMA Y

KEYSTONE 65 MEDICARE 852 KEMA Y

B/C Personal Choice 65 Medicare Replacement 861 PCMA Y

Medicare Advantage (Non Contracted) 888 MRA N

MEDICARE MCR ADVANTAGE (Non Contracted) New Selection during open enrollment period

890 MR1 N

UNIFORMED SVCS FAMILY HLTH PLN** 760 USFHP N

HORIZON NJ DIRECT MEDICARE ADVANTAGE 876 HMAP Y

57



09/2017

MULTIPLAN

Please add logo:

Multiplan (TPA) Third Party Administrator (TPA): Third Party Administrators serve as PPO Networks. TPAs provide administrative services to small employer groups and/or self funded Health Organizations; they re-price the claims to ensure the best payment rate. Benefit limitations may apply.



MULTI PLAN 43 ETH N

58



09/2017

OXFORD

PREFERRED HEALTH NETWORK

PLAN DESCRIPTION FSC # FSC Mnemonic Eligibility Enabled

OXFORD 151 OHP Y

59



09/2017

(MAX)

*Needs to be Deactivate



PREFERRED HEALTH NETWORK (MAXNET) 78* MAX N

60



09/2017

QUALCARE



QualCare 350 QC N

61



09/2017

THIRD PARTY ADMINISTRATORS (TPA)

TPA Listings Third Party Administrator (TPA): Third Party Administrators serve as PPO Networks. TPAs provide administrative services to small employer groups and/or self funded Health Organizations; they re-price the claims to ensure the best payment rate. Benefit limitations may apply.

PLAN DESCRIPTION FSC # FSC Mnemonic Eligibility Enabled

AETNA TPA (Aetna Signature Administrators) 462 ATPA N Devon 165 AMRC N Intergroup 454 ITG N Preferred Health Network (MAXNET) 78 MAX N Multiplan 43 ETH N MagnaCare PPO 189 MAGP N

62



09/2017

CHAMPUS (TRICARE)

TRICARE Prime participation through US Family Health Plan. All other TRICARE Products are non-par but may have out of network benefits.



CHAMPUS/HEALTHNET 47 CHA Y

Tricare For Life (Secondary To Medicare) 50 CIM Y

CHAMPVA 41 CI N

63



09/2017

UNION INSURANCE (LOCAL UNIONS)



COMMERCIAL-Primary 41 CI N

COMM INSUR-2NDRY 44 CIS N


64



09/2017

UNITED BEHAVIORAL HEALTH

NON-PAR Plan



UNITED BEHAVIORAL HEALTH-for Group 3 398 MENT N

UNITED BEHAVIORAL HEALTH-for Group 4 198 MENH N

UNITED BEHAVIORAL HEALTH-for Group 7 798 MHLT N

65



09/2017

UNITED HEALTHCARE/GOLDEN RULE



UNITED HEALTHCARE HMO 76 MLN Y

66



09/2017

UNITED HEALTHCARE GROUP - (SUMMARY PAGE)

. . AARP Certified users will continue registering patients presenting with Medicare primary and have AARP as secondary insurance coverage in the IDX-FSC listed above. AARP Healthcare Options offers primary personal health insurance plans to qualifying individuals. Individuals between the ages of 50 to 64 have several plans available from which to choose. Please note that these plan benefits include large out-of-pocket expenses and limitations. Patients presenting for services with this product should be registered as described above. .



UNITED HEALTHCARE - HMO 76 MLN Y UNITED HEALTHCARE COMMUNTY PLAN (formerly Americhoice of NJ) 451 ACNJ

Y

UNITED HEALTHCARE COMMUNITY PLAN 2NDRY (formerly Americhoice of NJ)

207 AC2 Y

ONENET PPO (formerly Alliance PPO) 41 CI N

OXFORD 151 OHP Y

AARP (Secondary to Medicare) Medigap 50 CIM Y

AARP (Primary Commercial Plans) 41 CI Y

UNITED BEHAVIORAL HEALTH-for Group 3 398 MENT N

UNITED BEHAVIORAL HEALTH-for Group 4 198 MENH N

UNITED BEHAVIORAL HEALTH-for Group 7 798 MHLT N

67



09/2017

US FAMILY HEALTH PLAN

TRICARE PRIME



UNIFORMED SVCS FAMILY HLTH PLN 760 USFHP N

68



09/2017

VALUE OPTIONS BEHAVIORAL HEALTH

RowanSOM has entered into an agreement with Value Options Behavioral Health services comprising Horizon Blue Cross Blue Shield (BC/BS) family of plans including Horizon NJ Health Medicaid. Value Options will replace Magellan Health Services for the Horizon Blue Cross Blue Shield (BC/BS) family of plans. Individuals enrolled with Horizon NJ Health plan, behavioral health benefits will include Developmental Disabilities, and Managed Long Term Services & Support (MLTSS) only under Value Options. Individuals with the Horizon NJ Health plan receiving behavioral health services coinciding with routine outpatient services, urgent/emergent and/or acute medical admissions should be billed to NJ Medical Assistance (NJMA). Patient present for service on or after July 1, 2014 should be registered as described above. Claims Submission Address Horizon Value Options Horizon Behavioral Health PO Box 10191 Newark, NJ 07101‐3189 Payer ID No. 22099



Value Options HMO GRP#3 340 VAH N

Value Options Non-HMO GRP#3 399 VAL N

Value Options HMO GRP#4 440 VOH N

Value Options Non-HMO GRP#4 499 VLU N

Value Options HMO GRP#7 740 VOL N

Value Options Non-HMO GRP#7 799 VLO N

69



09/2017

VETERANS ADMINISTRATION



COMMERCIAL-Primary 41 CI N

COMM INSUR-2NDRY 44 CIS N


To ensure RowanSOM receives payment for Veteran patients presenting for services, the following are required:

Pre-Authorization prior to rendering any medical services (7078 letter).

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