COBA Trading Partners March 31 2016

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner GROUP HEALTH, INC. (GHI)- HMO - SUPPLEMENTAL WELLMARK BCBS (FEP) WELLMARK BCBS OF IOWA (FEP) WELLMARK BCBS OF IOWA (FEP) WELLMARK BCBS OF IOWA (FEP) THE REGENCE GROUP (IDAHO-FEHBP) THE REGENCE GROUP (BLUE SHIELD--FEHBP) THE REGENCE GROUP (UTAH--FEHBP) THE REGENCE GROUP (OREGON--FEHBP) MONUMENTAL LIFE INSURANCE CO. (FORMERLY UNDER AEGON) - SUPPLEMENTAL CONNECTICUT GENERAL LIFE INSURANCE CO. (CIGNA) HORIZON BCBS OF NJ - SUPPLEMENTAL WELLMARK BCBS OF IOWA WELLMARK BCBS OF SD WELLMARK BCBS OF SD WISCONSIN PHYSICIAN SERVICES - COMMERCIAL WISCONSIN PHYSICIAN SERVICES - COMMERCIAL BCBS OF MICHIGAN BCBS OF ALABAMA - SUPPLEMENTAL BCBS OF SOUTH CAROLINA - SUPPLEMENTAL HIGHMARK, INC. - SUPPLEMENTAL PART B & DMERC HIGHMARK, INC. - SUPPLEMENTAL PART A ONLY GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL GROUP HEALTH, INC. (GHI) PPO - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- SUPPLEMENTAL BCBS OF MICHIGAN AETNA, INC. BCBS OF MICHIGAN BCBS OF MICHIGAN - BCN (BLUE CARE NETWORK) BLUE CROSS AND BLUE OF MISSISSIPPI - SUPPLEMENTAL BLUE CROSS AND BLUE OF MISSISSIPPI - SUPPLEMENTAL BLUE CROSS OF NORTHEASTERN PA - SUPPLEMENTAL (PART A ONLY) BLUE CROSS OF NORTHEASTERN PA - SUPPLEMENTAL (PART A ONLY) METROPOLITAN HEALTH PLAN - SUPPLEMENTAL PRIMEWEST HEALTH PLAN - SUPPLEMENTAL PRIMEWEST HEALTH PLAN - SUPPLEMENTAL Updated: 03/31/2016

Identification Number(s) 00002 00004 00005 00005 00006 00009 00010 00011 00012 00017 00018 00019 00020 00021 00023 00025 00026 00027 00028 00029 00030 00031 00032 00033 00034 00035 00036 00037 00041 00042 00044 00055 00060 00061 00062 00067 00068 00069 00070 00072 00073 00073

Customer Contact Customer Service Customer/Provider Services Provider Services Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer/Provider Services Customer/Provider Services Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer/Provider Services Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Cathy Stitzer Cathy Stitzer Bonnie Hays Provider Services Mary Winter

Contact Number (877) 244-4466 (800) 524-9242 (800) 524-9242 (800) 373-5348 (800) 524-9242 (800) 343-8915 (800) 343-8915 (800) 343-8915 (800) 343-8915 (800) 854-0186 (800) 244-6224 (800) 624-1110 (800) 524-9242 (800) 524-9242 (800) 524-9242 (888) 253-2694 (888) 253-2694 (313) 225-9000 (205) 988-2200 (800) 760-9290 (800) 345-3806 (800) 345-3806 (212) 501-4444 (212) 501-4444 (212) 501-4444 (212) 501-4444 (212) 501-4444 (212) 501-4444 (888) 762-2189 (888) 762-2189 (888) 762-2189 (313) 225-9000 (860) 273-0123 (313) 225-9000 (800) 450-3680 (800) 257-5825 (800) 257-5825 (570) 200-4540 (570) 200-4540 (612) 543-3338 (866) 431-0802 (320) 335-5239

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner TRIPLE S, INC. - SUPPLEMENTAL CAREFIRST OF DC - PART A ONLY CAREFIRST OF DC - PART B ONLY BCBS OF NORTH DAKOTA BCBS OF WYOMING - SUPPLEMENTAL (PART B & DMERC) BCBS OF NORTH DAKOTA MEDICAL MUTUAL OF OHIO - SUPPLEMENTAL BCBS OF TENNESSEE - SUPPLEMENTAL UNITED HEALTH CARE-UNET - SUPPLEMENTAL UNITED HEALTH CARE - SUPPLEMENTAL GROUP HEALTH COOPERATIVE - SUPPLEMENTAL BLUE CROSS AND BLUE SHIELD OF MINNESOTA - SUPPLEMENTAL BLUE CROSS AND BLUE SHIELD OF MINNESOTA - SUPPLEMENTAL BLUE CROSS AND BLUE SHIELD OF MINNESOTA - SUPPLEMENTAL EMPIRE BCBS - SUPPLEMENTAL EMPIRE BCBS - SUPPLEMENTAL BCBS OF KANSAS - SUPPLEMENTAL KPS HEALTH PLANS- SUPPLEMENTAL ANTHEM BCBS OF CT - SUPPLEMENTAL ANTHEM BCBS OF NH - SUPPLEMENTAL ANTHEM BCBS OF ME - SUPPLEMENTAL BCBS OF LOUISIANA - SUPPLEMENTAL NEW JERSEY CARPENTERS HEALTH FUND - SUPPLEMENTAL MAYO MEDICAL SYSTEMS, INC. (MMSI) - SUPPLEMENTAL WEA INSURANCE COMPANY - SUPPLEMENTAL CAREFIRST OF DC - SUPPLEMENTAL CAREFIRST OF DC - SUPPLEMENTAL CAREFIRST OF MD - SUPPLEMENTAL EMPIRE BCBS - SUPPLEMENTAL EMPIRE BCBS - SUPPLEMENTAL CARPENTERS TRUST OF WESTERN WASHINGTON BLUE SHIELD OF CALIFORNIA - SUPPLEMENTAL BCBS OF NORTH CAROLINA CAPITAL BLUE CROSS - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BCBS OF WESTERN NEW YORK - SUPPLEMENTAL BLUE CROSS AND BLUE SHIELD OF DELAWARE - SUPPLEMENTAL Updated: 03/31/2016

Identification Number(s) 00074 00075 00076 00077 00078 00079 00080 00081 00082 00083 00087 00088 00089 00090 00091 00092 00093 00094 00095 00096 00097 00099 00102 00103 00104 00105 00106 00107 00108 00109 00110 00111 00112 00113 00114 00114 00114 00115 00115 00115 00116 00118

Customer Contact Jeannette Irizarry Velez Provider Services Provider Services Gina Bercherl Amber Zowada Gina Bercherl Sue Robinson Customer Service Customer Service Customer Service Michelle Anderson Customer Service Customer Service Customer Service Lora Tincher Lora Tincher Customer Service Teresa Hiagh-Braget Lora Tincher Lora Tincher Lora Tincher Customer Service Rachel Corradi Customer Service Shawn Lynn Part A only Part B only Part B only Customer Service Customer Service Min-Sug (Darren) Kong Tammy Rutters eSolutions Help Desk Nancy Herman Buffalo (CNY West) Albany Region II Albany (CNY East) Traditional Member Managed Care Member Provider Services Melissa Deboth Customer Service

Contact Number (787) 749-4949 (410) 998-4599 (410) 998-4599 (701) 277-2081 (307) 432-2743 (701) 277-2081 (800) 700-2583 (800) 553-8158 (866) 633-2446 (866) 633-2446 (206) 901-4588 (800) 531-6686 (800) 531-6686 (800) 531-6686 (502) 310-9374 (502) 310-9374 (800) 432-3990 (360) 478-2635 (502) 310-9374 (502) 310-9374 (502) 310-9374 (800) 392-4089 (732) 417-3900 ext. 272 (800) 635-6671 (608) 661-6617 (410) 998-4599 (410) 998-4599 (410) 998-4599 (800) 435-1385 (800) 435-1386 (206) 441-6514 (530) 351-6109 (888) 333-8594 (717) 541-6274 (866) 638-9011 (800) 945-0566 (800) 856-0480 (800) 888-1238 (800) 459-7587 (800) 444-4552 (716) 887-8443 (302) 429-0260

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner HEALTH ALLIANCE PLAN OF MICHIGAN - SUPPLEMENTAL BCBS OF ARIZONA - SUPPLEMENTAL MERCER HEALTH & BENEFITS, LLC ALLEGIANCE BENEFIT PLAN MANAGEMENT EMPLOYEE BENEFIT MANAGEMENT CARE - SUPPLEMENTAL ANTHEM BCBS-CENTRAL (FACETS) -IN, KY, OH - SUPPLEMENTAL HEALTH DESIGN PLUS ANTHEM NATIONAL BCBS OF OHIO - SUPPLEMENTAL ANTHEM NATIONAL BCBS OF KENTUCKY - SUPPLEMENTAL ANTHEM NATIONAL BCBS OF INDIANA - SUPPLEMENTAL ANTHEM BCBS OF ME - SUPPLEMENTAL ANTHEM BCBS OF NH - SUPPLEMENTAL ANTHEM BCBS OF CT - SUPPLEMENTAL ANTHEM BCBS OF VIRGINIA - SUPPLEMENTAL ODS HEALTH PLANS, INC. - SUPPLEMENTAL ARKANSAS BCBS - SUPPLEMENTAL ARKANSAS BCBS (HEALTH ADVANTAGE) - SUPPLEMENTAL NATIONWIDE HEALTH PLANS - SUPPLEMENTAL PITTMAN & ASSOCIATES, INC. - SUPPLEMENTAL HEALTH ALLIANCE MEDICAL PLANS - SUPPLEMENTAL GRAPHIC COMMUNICATIONS NAT'L ANTHEM BCBS OF NEVADA ANTHEM BCBS OF COLORADO BLUE CROSS OF CALIFORNIA - SUPPLEMENTAL UNICARE LIFE & HEALTH INSURANCE COMPANY - SUPPLEMENTAL HEALTHNET, INC-- CA -SUPPLEMENTAL INSURANCE PROGRAMMERS INC. RESERVE NATIONAL INSURANCE CO BC OF IDAHO - SUPPLEMENTAL BC OF IDAHO - SUPPLEMENTAL ALLIED BENEFIT SYSTEMS, INC - SUPPLEMENTAL ALLIED BENEFIT SYSTEMS, INC - SUPPLEMENTAL NGS AMERICAN - SUPPLEMENTAL HIGHMARK WEST VIRGINIA HIGHMARK WEST VIRGINIA UMR PENNSYLVANIA EMPLOYEE BENEFIT TRUST FUND (PEBTF) - SUPPLEMENTAL PENNSYLVANIA EMPLOYEE BENEFIT TRUST FUND (PEBTF) - SUPPLEMENTAL PREMERA BLUE CROSS - SUPPLEMENTAL POMCO, INC. - SUPPLEMENTAL

Updated: 03/31/2016

Identification Number(s) 00119 00122 00123 00124 00127 00128 00130 00131 00134 00136 00139 00140 00141 00148 00150 00151 00153 00154 00156 00157 00160 00166 00168 00170 00171 00173 00180 00182 00184 00185 00188 00188 00189 00190 00191 00192 00208 00208 00209 00210

Customer Contact Laron Gaines Rebecca Garcia

Contact Number (313) 664-7123 (602) 864-4818

Customer Service Customer Service Customer Service Customer Service Lora Tincher Customer Service Customer Service Lora Tincher Lora Tincher Lora Tincher Part A only EDI Department Mia Moore Dee McKee Customer Service Andy Glankler Cindy Cargo Teresa Bauer Lora Tincher Lora Tincher Lora Tincher Lora Tincher Customer Service Amy Cook Reta Weaver Customer Service Customer Service Outside IL IL Resident Customer Service Customer Service Customer Service Customer Service Rest of U.S. In Pennsylvania Customer Service Vivie Prichard

(406) 721-2222 (800) 993-3262 (866) 649-2037 (800) 549-9114 (502) 310-9374 (800) 880-2583 (317) 287-5000 (502) 310-9374 (502) 310-9374 (502) 310-9374 (800) 451-0361 (800) 852-5195 (501) 502-1686 (501) 212-8520 (877) 234-2727 (901) 473-3344 (217) 383-8208 (412) 201-2242 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (800) 641-7761 (203) 269-7741 (800) 654-9106 (866) 482-2253 (866) 482-2253 (800) 288-2078 (312) 906-8080 (800) 521-1555 (800) 543-7822 (800) 543-7822 (800) 826-9781 (800) 522-7279 (717) 565-7410 (800) 722-1471 (800) 830-2528

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner BCBS OF MASS HEALTHSMART BCBS OF VERMONT - SUPPLEMENTAL OXFORD HEALTH - SUPPLEMENTAL UNITED HEALTH CARE- COSMOS - SUPPLEMENTAL C & R CONSULTING - SUPPLEMENTAL CORESOURCE, INC. - SUPPLEMENTAL CORESOURCE, INC. - SUPPLEMENTAL CORESOURCE, INC. - SUPPLEMENTAL BCBS OF KANSAS CITY BCBS OF RHODE ISLAND UNITED HEALTHCARE (SUPPLEMENTAL) MERITAIN HEALTH, INC. ASURIS REGENCE BLUESHIELD OF UTAH REGENCE BLUESHIELD REGENCE BCBS OF OREGON REGENCE BLUESHIELD OF IDAHO CLAIMSNET.COM, INC. - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - SUPPLEMENTAL HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- SUPPLEMENTAL KIDNEY DISEASE PROGRAM OF MARYLAND - SUPPLEMENTAL AMALGAMATED LIFE/ALICARE - SUPPLEMENTAL HUMANA, INC. - SUPPLEMENTAL JP FARLEY COMPREHENSIVE BENEFITS CONSULTANTS (A.K.A. "FEDERATED ALLIED RETIREE ASSOCIATION")SUPPLEMENTAL UCARE MINNESOTA - SUPPLEMENTAL UCARE MINNESOTA - SUPPLEMENTAL C & O EMPLOYEE HOSPITAL - SUPPLEMENTAL PIPE FITTERS WELFARE FUND CONNECTICUT GENERAL LIFE INSURANCE CO. (CIGNA) PLUMBER LOCAL 130 UA NATIONAL ELEVATOR INDUSTRY HEALTH BE BCBS OF NORTH CAROLINA ANTHEM BCBS OF VIRGINIA - SUPPLEMENTAL THE LOOMIS COMPANY BCBS OF WYOMING -(PART A) WEB TPA SECURITY HEALTH PLAN OF WI, INC.

Updated: 03/31/2016

Identification Number(s) 00212 00214 00217 00220 00224 00226 00229 00229 00229 00232 00236 00237 00240 00246 00249 00250 00251 00252 00253 00254 00255 00256 00259 00267 00268 00280 00288 00292 00292 00295 00299 00300 00304 00305 00306 00308 00310 00312 00313 00314

Customer Contact Customer Service

Contact Number (800) 258-2226

Chantal Parent Customer Service Stewart McGehee C&R Customer One Beacon Ins Grp Crompton Corp All others Kathy Currey Customer Service Stewart McGehee Customer Service Rebecca Thorn Rebecca Thorn Rebecca Thorn Rebecca Thorn Rebecca Thorn Customer Service Customer Service Customer Service Customer Service Carol Manning Customer Service Customer Service Amanda Smolka

(802) 371-3611 (888) 201-4133 (336) 540-7563 (212) 819-0792 (866) 889-7286 (866) 318-7173 (800) 223-3943 (816) 395-3877 (800) 267-0439 (336) 540-7563 (800) 548-2041 (503) 375-4341 (503) 375-4341 (503) 375-4341 (503) 375-4341 (503) 375-4344 (817) 878-3300 (888) 762-2189 (888) 762-2189 (888) 762-2189 (410) 767-5004 (212) 539-5111 (866) 427-7478 (440) 250-4316

Lorraine Piazza Provider Customer Service Member Assistance Anna Brooks

(631) 249-0500 (888) 531-1493 (877) 523-1515 (540) 862-5728

Customer Service

(800) 244-6224

ESolutions Help Desk Michael Bristoe

1(888)333-8594 (502) 727-7280

Amber Zowada Lisa Smith Ken Baur

(307) 432-2743 (469) 417-1854 (715) 221-9556

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF OK (OTHER A ONLY) HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF OK (OTHER B ONLY) CAPITOL DISTRICT PHYSICIANS’ HEALTH PLAN WEBTPA EMPLOYER SERVICES RMSCO INC TIC – BAC LOCAL UNION 15 W.F.

Identification Number(s) 00317 00318 00321 00322 00323 00326

Customer Contact Customer Service Customer Service Brian Freer Lisa Smith Jen Springler Michelle Cockerham

Contact Number (888) 762-2189 (888) 762-2189 (518) 641-3820 (469) 417-1854 (315) 448-9001 (913) 236-5490

TIC – IBEW LOCAL 461 WELFARE FUND TIC – ELECTRICAL WORKERS FUND BLUE CROSS OF NORTHEASTERN PA BLUE CROSS OF NORTHEASTERN PA BLUE CROSS OF NORTHEASTERN PA BLUE CARE COOPERATIVE PLUMBERS’ AND PIPEFITTERS’ WELFARE FUND DANA NON UNION RETIREE VEBA TRUST BLUE CROSS OF NORTHEASTERN PA G.M.P. - EMPLOYERS RETIREE TRUST MEDICA (PART B ONLY) MEDICA (PART A ONLY)

00329 00332 00333 00334 00335 00341 00343 00352 00353 00354 00360 00361

Susan Esterhai Jackie Neible Cathy Stitzer Cathy Stitzer Cathy Stitzer Cathy Stitzer Nancy Winer Lorraine Piazza Cathy Stitzer Amy Thomas Stephanie Kelly Stephanie Kelly

(866) 461-4239 (317) 923-4577 (570) 200-4540 (570) 200-4540 (570) 200-4540 (570) 200-4540 (314) 355-1000 (631) 249-0500 (570) 200-4540 (239) 936-6242 (952) 992-2582 (952) 992-2582

CONNECTICUT GENERAL LIFE INSURANCE CO. BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA AVMED HEALTH PLANS PIPELINE INDUSTRY BENEFIT FUND THE WILLIAM C. EARHART CO., INC MID CENTRAL OPERATING ENGINEERS HEALTH & WELFARE FUND SOUTHWEST LIFE & HEALTH INS. CO. FIRSTCARE WABASH MEMORIAL HOSPITAL ASSOC. AMERICAN BENEFIT CORPORATION TIC – NECA IBEW LOCAL 364 HEALTH RIGHT CHOICE BENEFIT ADMIN. BCBS OF NEBRASKA BCBS OF NEBRASKA HP ADMINISTATIVE SERVICES, LLC ADC 1 WELFARE FUND BLUE SHIELD OF CALIFORNIA - SFEW

00364 00366 00367 00368 00369 00370 00371 00372 00374 00375 00377 00378 00379 00380 00386 00387 00388 00392 00402 00406 00407

Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Claims Supervisor Pam Fleischman Katricia Helton Melinda Rodriguez Melinda Rodriguez Debby Kunze Linda Sites Medical Claims Department Customer Service Right Choice Customer Service Center Customer Service Center Jenny Ray Yolanda Alzati Lisa Schultz

(800) 244-6224 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 882-8633 (918) 280-4800 (503) 331-8209 (812) 232-4384 (806) 784-4378 (806) 784-4378 (217) 429-5246 (304) 525-0331 (800) 228-0048 (800) 365-9036 (800) 991-7392 (800) 991-7392 (405) 416-1514 (630) 617-8630 (415) 263-3670

Updated: 03/31/2016

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner IE SCHAFFER & CO C & R CONSULTING ARKANSAS BCBS COVENTRY NATIONAL ACCOUNTS EMBLEMHEALTH SVC CO. LLC - VYTRA EMBLEMHEALTH SVC COMPANY, LLC - HIP M.C.D.C HEALTH FUND PLUMBERS & PIPEFITTERS LOCAL 630 OE LOCAL 139 HBF PIPE TRADES INDUSTRY H&W PLAN HEALTHNET OF ARIZONA, INC. C&R CONSULTING BLUE SHIELD OF CALIFORNIA SCPT HEALTH & WELFARE FUND LIBERTY NATIONAL LIFE INSURANCE CO. - GMS GUNDERSEN LUTHERAN HEALTH PLAN SENTARA HEALTH PLANS INC. INDIANA LABORERS WELFARE FUND INDIANA LABORERS WELFARE FUND AMERICAN BENEFIT CORPORATION BCBS OF LOUISIANA HEALTH CARE SERVICE CORP, BCBS HEALTH CARE SERVICE CORP, BCBS KAISER FOUNDATION HEALTH PLAN INDEPENDENCE BLUE CROSS OPERATING ENGINEERS H&W FUND TIC-NECA IBEW LCL 150 FRINGE BF FABIAN & BYRN LLC DELTA HEALTH SERVICES, INC. HARRINGTON HEALTH SERVICES, INC. NECA FAMILY MEDICAL CARE PLAN BLUE CROSS BLUE SHIELD OF GA KCSUP BLUE CROSS BLUE SHIELD OF GA KCSUP EIGHTH DISTRICT ELECTRICAL BENEF MEDICAL ASSOC HEALTH PLAN INC WEST MICH. PLUMBERS, FITTERS NATIONAL BCBS GEORGIA DESERET MUTUAL Updated: 03/31/2016

Identification Number(s) 00411 00413 00417 00420 00422 00423 00425 00426 00427 00428 00429 00431 00433 00434 00435 00436 00438 00439 00440 00445 00455 00456 00457 00459 00460 00462 00463 00467 00470 00473 00474 00475 00476 00478 00479 00484 00485 00486

Customer Contact Terri Trasatti

Contact Number (609) 883-6688

Mia Moore Customer Service Robyn Callahan Robyn Callahan Sandra Belot Amanda Ratcliff Annette Kusick Pam Lewis Healthnet Provider Service

(501) 502-1686 (800) 937-6824 (631) 577-5091 (631) 577-5091 (262) 970-5790 (954) 266-6322 (262) 549-9190 (812) 877-2581 (800) 977-7522

Tammy Rutters Marcus Chin Customer Service Department Ann Kiel Todd Kelly Melissa Wade Melissa Wade Linda Sites Customer Service Blue Cross Blue Shield Blue Cross Blue Shield Member Service Sharelle Bond Elisabeth Schaefer Jan Smith Talisha Douglas Christine Dugger-Praet Customer Service Vicki Burrows Lora Tincher Lora Tincher Mary Kemp Laura Boge Customer Service Lora Tincher Donna Mcreavy

(530) 351-6109 (213) 385-6161 (972) 529-5085 (608) 775-8070 (757) 552-7237 (812) 238-2551 (812) 238-2551 (304) 525-0331 (800) 392-4089 (888) 762-2189 (888) 762-2189 (800) 777-7902 (215) 241-9227 (626) 356-3560 (877) 478-4542 (973) 228-4200 (559) 228-4185 (800) 216-2166 (877) 937-9602 (502) 310-9374 (502) 310-9374 (801) 973-1001 (563) 556-8070 (219) 769-6944 (502) 310-9374 (801) 578-5621

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner REGENCE BLUE SHIELD WISCONSIN PHYSICIANS SERVICE WISCONSIN PHYSICIANS SERVICE IAHFI LOCAL 17 WELFARE FUND HEALTHLINK HMO, INC INDEPENDENCE BLUE CROSS PEHP HEALTH CARE SERVICE CORPORATION HEALTH CARE SERVICE CORPORATION WELLMARK BCBS OF SD WELLMARK BCBS OF IA MIDWEST OPERATING ENGINEERS HEALTH NEW YORK ISG NEVADA ISG MAINE ISG WISSONSIN ISG KENTUCKY ISG VIRGINIA ISG NEW HAMPSHIRE ISG MISSOURI ISG OHIO ISG CALIFORNIA ISG COLORADO ISG CONNECTICUT ISG INDIANA ISG CONNECTICUT WGS INDIANA WGS KENTUCKY WGS MISSOURI WGS NEW YORK WGS OHIO WGS VIRGINIA WGS WISCONSIN WGS INDEPENDENCE BLUE CROSS INDEPENDENCE BLUE CROSS BCBS of NORTH Carolina AFTRA HEALTH FUND BCBS of MINNESOTA BCBS of MINNESOTA WESTERN & SOUTHERN FINANCIAL GROUP MERCER HEALTH & BENEFITS ADM. LLD

Updated: 03/31/2016

Identification Number(s) 00489 00493 00494 00495 00498 00500 00501 00502 00503 00506 00507 00508 00509 00510 00511 00512 00513 00514 00515 00516 00517 00518 00519 00520 00521 00522 00523 00524 00526 00528 00529 00530 00531 00532 00533 00535 00537 00544 00545 00554 00571

Customer Contact Rebecca Thorn Kit Lee Kit Lee William Mangin Karen Gotsch Sharelle Bond Josie Hall Blue Cross/Blue Shield Blue Cross/Blue Shield Customer/Provider Services Customer/Provider Services Barbara Glembin Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Sharelle Bond Sharelle Bond Pam Stephenson Karen Ortolani Customer Service Customer Service John Kaising Dee Green

Contact Number (503) 375-4341 (608) 226-3369 (608) 226-3369 (708) 468-8000 (314) 925-6166 (215) 241-9227 (801) 366-7519 (888) 762-2189 (888) 762-2189 (800) 524-9242 (800) 524-9242 (708) 579-6603 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (215) 241-9227 (215) 241-9227 (919) 765-4379 (800) 562-4690 (800) 531-6686 (800) 531-6686 (513) 357-4007 (515) 365-6374

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner MONUMENTAL LIFE INSURANCE CO. AARP/UNITED HEALTH CARE (DOING BUSINESS AS “UNITED HEALTH GROUP”) MEDIGAP WELLMARK BCBS OF SD WELLMARK BCBS OF IA MONUMENTAL LIFE INSURANCE CO. (FORMERLY UNDER AEGON) MEDIGAP HORIZON BCBS OF NJ - MEDIGAP BCBS OF SC HIGHMARK, INC. - MEDIGAP PAT B & DMERC HIGHMARK, INC. - MEDIGAP PART A ONLY GROUP HEALTH, INC. (GHI) PPO - MEDIGAP GROUP HEALTH, INC. (GHI) PPO - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- MEDIGAP HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- MEDIGAP LIBERTY NATIONAL LIFE INSURANCE CO. (AFFILIATED WITH TORCHMARK) LIBERTY NATIONAL LIFE INSURANCE CO. (AFFILIATED WITH TORCHMARK) GLOBAL LIFE & ACCIDENT INSURANCE CO. (AFFILIATED WITH TORCHMARK) AMERICAN INCOME LIFE INSURANCE CO. (AFFILIATED WITH TORCHMARK) UNITED AMERICAN INSURANCE COMPANY (TORCHMARK) - MEDIGAP FIRST UNITED AMERICAN LIFE INS. CO. EQUITABLE LIFE & CASUALITY INS. CO. BLUE CROSS AND BLUE OF MISSISSIPPI - MEDIGAP BLUE CROSS OF NORTHEASTERN PA - MEDIGAP (PART A ONLY) BLUE CROSS OF NORTHEASTERN PA - MEDIGAP (PART A ONLY) TRIPLE S, INC. - MEDIGAP BCBS OF WYOMING - MEDIGAP (PART A, B, DMERC) BCBS OF NORTH DAKOTA BCBS OF TENNESSEE - MEDIGAP UNITED COMMERCIAL TRAVELERS - MEDIGAP STANDARD LIFE ACCIDENT INSURANCE COMPANY (SLA) - MEDIGAP SLA/AMERICAN NATIONAL LIFE INSURANCE CO. (ANICO) OF TEXAS - MEDIGAP LOYALAM/UNITEDTEACH/GREATAMLIFE GUARANTEE TRUST LIFE INSURANCE COMPANY - MEDIGAP (DMERC IN ALL STATES AND PART-B IN ALL STATES EXCEPT MN AND WI) EMPIRE BCBS - MEDIGAP BLUE CROSS AND BLUE SHIELD OF MINNESOTA - MEDIGAP BLUE CROSS AND BLUE SHIELD OF MINNESOTA - MEDIGAP BLUE CROSS AND BLUE SHIELD OF MINNESOTA - MEDIGAP

Updated: 03/31/2016

Identification Number(s) 30000 30002 30003 30004 30006 30013 30016 30017 30018 30019 30020 30023 30024 30025 30026 30027 30028 30029 30030 30032 30033 30034 30035 30036 30039 30040 30041 30042 30045 30046 30047 30048 30051 30052 30054 30055 30056 30057 30058 30059

Customer Contact Jennifer Havens Customer Service Customer/Provider Services Provider Services Jennifer Havens Customer Service Judith Murray Customer Service Customer Service Geraldine Holmes Geraldine Holmes Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Laura Sarle Customer Service Cathy Stitzer Cathy Stitzer Jeannette Irizarry Velez Amber Zowada Gina Bercherl Venessa Marsh Jose Viri-Dunahue Jill Davis Jill Davis Customer Service Mark Pytel

Contact Number (610) 648-4990 (800) 523-5800 (800) 524-9242 (800) 524-9242 (610) 648-4990 (800) 624-1110 (803) 264-3889 (800) 345-3806 (800) 345-3806 (315) 434-2437 (315) 434-2437 (888) 762-2189 (888) 762-2189 (888) 762-2189 (888) 762-2189 (888) 762-2189 (888) 762-2189 (972) 529-5085 (972) 529-5085 (972) 529-5085 (972) 529-5085 (972) 529-5085 (972) 529-5085 (801) 579-3464 (800) 257-5825 (570) 200-4540 (570) 200-4540 (787) 749-4949 (307) 432-2743 (701) 277-2081 (423) 535-4930 (614) 487-9680 (281) 538-4890 (281) 538-4890 (866) 459-4272 (847) 904-5375

Lora Tincher MN only non-MN DMERC only

(502) 310-9374 (800) 531-6686 (800) 531-6686 (800) 531-6686

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner MEDICAL MUTUAL OF OHIO - MEDIGAP KANSAS BCBS - MEDIGAP PROVIDENCE HEALTH PLAN KPS HEALTH PLANS- MEDIGAP (PART B ONLY) BANKERS LIFE AD CASUALITY CONSECO SERVICES, LLC - MEDIGAP ANTHEM BCBS NORTHEAST REGION CONSECO, LLC/ COLONIAL PENN -MEDIGAP SANDFORD HEALTH PLAN OF MINNESOTA - MEDIGAP SANFORD HEALTH PLAN HEALTH ALLIANCE MEDICAL PLANS OF URBANA, IL - MEDIGAP CONTINENTAL LIFE INS. CO OF BRENTWOOD, TN - MEDIGAP AMERICAN CONTINENTAL INSURANCE PHYSICIANS MUTUAL INSURANCE COMPANY - MEDIGAP DEAN HEALTH PLAN, INC. - MEDIGAP CAREFIRST OF MD (PART A ONLY) - MEDIGAP PARAMOUNT HEALTH PLANS - MEDIGAP UPMC FOR LIFE MEDICARE SELECT - MEDIGAP BLUE SHIELD OF CALIFORNIA - MEDIGAP CAPITAL BLUE CROSS BLUE CROSS BLUE SHIELD OF WNY BLUE CROSS BLUE SHIELD OF WNY MUTUAL OF OMAHA INSURANCE COMP MUTUAL OF OMAHA INSURANCE COMP BLUE CROSS AND BLUE SHIELD OF DELAWARE - SUPPLEMENTAL EVERENCE ASSN A FRATERNAL BCBS OF ARIZONA - MEDIGAP SIERRA HEALTH & LIFE - MEDIGAP BCBS OF NORTH DAKOTA ANTHEM BCBS-CENTRAL (FACETS) - IN, KY, OH - MEDIGAP GUARANTEE TRUST LIFE INSURANCE COMPANY - MEDIGAP (PART-B IN MN AND WI ONLY) ANTHEM BCBS OF VIRGINIA - MEDIGAP ANTHEM BCBS OF VIRGINIA - MEDIGAP ANTHEM BCBS NORTHEAST REGION ODS HEALTH PLANS, INC. - MEDIGAP ARKANSAS BCBS - MEDIGAP INDEPENDENCE BLUE CROSS - MEDIGAP CENTRAL UNITED LIFE INSURANCE COMPANY - MADIGAN AFLAC OF CO - MEDIGAP AFLAC OF NY - MEDIGAP

Updated: 03/31/2016

Identification Number(s) 30060 30062 30063 30064 30065 30066 30067 30068 30069 30070 30071 30073 30074 30075 30076 30077 30078 30080 30083 30087 30088 30089 30090 30091 30093 30094 30095 30096 30097 30098 30103 30104 30105 30107 30108 30109 30110 30111 30113 30114

Customer Contact Sue Robinson Customer Service Customer Service Teresa Hiagh-Braget Customer Service Customer Service Lora Tincher Customer Service Tami Haberer Tami Haberer Cindy Cargo Katrina Smithson Katrina Smithson Alan Schoening Murielle Sago Provider Services Donya Hensley Robert Burtner Tammy Rutters Nancy Herman Melissa Deboth Melissa Deboth Customer Service Customer Service Customer Service Customer Service Rebecca Garcia Gina Bercherl Lora Tincher Mark Pytel Lora Tincher Lora Tincher Lora Tincher EDI Department Mia Moore Sharelle Bond Customer Service Customer Service Customer Service

Contact Number (216) 687-6108 (800) 432-3990 (800) 603-2340 (360) 478-2635 (800) 621-3724 (800) 621-3724 (502) 310-9374 (800) 523-4000 (605) 328-6860 (605) 328-6860 (217) 383-8208 (800) 264-4000 (800) 264-4000 (402) 930-2785 (608) 827-4432 (800) 842-5975 (419) 887-2437 (412) 454-7889 (530) 351-6109 (717) 541-6274 (716) 887-8443 (716) 887-8443 (800) 775-1000 (800) 775-1000 (302) 429-0260 (574) 533-9511 ext. 380 (602) 864-4018 (701) 277-2081 (502) 310-9374 (847) 904-5375 (502) 310-9374 (502) 310-9374 (502) 310-9374 (503) 228-6554 (501) 502-1686 (215) 241-9227 (800) 669-9030 (800) 992-3522 (800) 992-3522

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner HIGHMARK WEST VIRGINIA HIGHMARK WEST VIRGINIA UNIFIED LIFE INS. CO. - MEDIGAP ANTHEM BCBS OF NEVADA - MEDIGAP ANTHEM BCBS OF COLORADO BLUE CROSS OF CALIFORNIA - MEDIGAP UNIFCARE LIFE & HEALTH INSURANCE COMPANY - MEDIGAP HEALTHPLUS OF MICHIGAN - MEDIGAP RESERVE NATIONAL INSURANCE CO AMERICAN INSURANCE ADMINISTRATORS - MEDIGAP BANKERS FIDELITY LIFE INS. CO. - MEDIGAP BC OF IDAHO - MEDIGAP BC OF IDAHO - MEDIGAP NORTH AMERICAN INSURANCE PEKIN LIFE INS. CO. - MEDIGAP STATE FARM AUTOMOBILE INSURANCE COMPANY - MEDIGAP THRIVENT FINANCIAL - MEDIGAP THRIVENT FINANCIAL - MEDIGAP BCBS OF MASS BCBS OF VERMONT - MEDIGAP BCBS OF KANSAS CITY AMERICAN REPUBLIC INSURANCE COMPANY - MEDIGAP WORLD INSURANCE CENTRAL STATES HEALTH & LIFE CO. OF OMAHA - MEDIGAP BCBS OF RHODE ISLAND MARSH AFFINITY GROUP SERVICES - MEDIGAP ASURIS REGENCE BLUESHIELD OF UTAH REGENCE BLUESHIELD REGENCE BLUESHIELD OF UTAH BCBS OF FLORIDA - MEDIGAP (FEP) BCBS OF FLORIDA - MEDIGAP (SUPPLEMENTAL) AMERI HEALTH ADMINISTRATOR- MEDIGAP COMMUNITYCARE LIFE & HEALTH - MEDIGAP AMERICAN REPUBLIC INSURANCE COMPANY - MEDIGAP REGENCE BCBS OF OREGON BCBS OF WISCONSIN BCBS OF WYOMING -(PART A) NATIONWIDE MUTUAL INS CO AMERICAN REPUBLIC INSURANCE COMPANY - MEDIGAP

Updated: 03/31/2016

Identification Number(s) 30117 30124 30129 30131 30135 30136 30137 30138 30149 30151 30152 30153 30154 30155 30156 30159 30166 30167 30168 30169 30171 30176 30180 30181 30184 30185 30187 30188 30189 30190 30192 30193 30203 30205 30208 30209 30220 30224 30225 30227

Customer Contact Customer Service Customer Service Jana Shrum Lora Tincher Lora Tincher Lora Tincher Lora Tincher Venus Pope Reta Weaver Bob Fabbi

Contact Number (800) 543-7822 (800) 543-7822 (913) 871-7312 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (810) 230-2018 (800) 654-9106 (727) 726-0726

Julie Tauber Customer Service Customer Service Rebecca Freeman Rebecca Freeman Debra Wilson Chantal Parent Kathy Currey Customer Service Customer Service Melissa Matthys Anne Brunson

(800) 627-4282 (800) 322-0160 (866) 855-1212 (920) 628-2329 (920) 628-2329 (617) 246-7665 (802) 371-3611 (816) 395-3877 (800) 247-2190 (800) 786-5443 (281) 368-7131 (800) 267-0439

Rebecca Thorn Rebecca Thorn Rebecca Thorn Rebecca Thorn Customer Service Customer Service Robert Johnston Roxanne King Customer Service Rebecca Thorn Lora Tincher Amber Zowada Tom Litton Customer Service

(503) 375-4341 (503) 375-4341 (503) 375-4341 (503) 375-4341 (800) 352-2583 (800) 352-2583 (215) 793-3042 (918) 594-5295 (800) 247-2190 (503) 375-4341 (502) 310-9374 (307) 432-2743 (614) 677-3788 (800) 247-2190

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner AMERICAN REPUBLIC INSURANCE COMPANY - MEDIGAP ROCKY MOUNTAIN HEALTH PLAN OLD SURETY LIFE INSURANCE CO. HEALTH ALLIANCE PLAN UNITED AMERICAN INSURANCE CO-GMS MEDICO WI PART A MEDICO WI PART B MEDICO PART A MEDICO PART B BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA ACTUARIAL MANAGEMENT RESOURCES FIRST COMMUNITY HEALTH PLAN, INC HEALTH CARE SERVICE BCBS-STD HCSC,BCBS NON-STD BCBS OF NEBRASKA BCBS OF NEBRASKA BLUE CROSS BLUE SHIELD OF NC HEARTLAND NATIONAL LIFE INS., CO. INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP

Identification Number(s) 30228 30229 30231 30232 30233 30236 30237 30238 30239 30242 30243 30244 30245 30246 30248 30250 30253 30254 30255 30256 30257 30275 30276 30276 30276 30276 30276 30276 30276 30276 30276 30276 30276 30276

INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP INSURANCE ADMINISTRATIVE SOLUTIONS, LLC - MEDIGAP

Updated: 03/31/2016

Customer Contact Customer Service Kris Malean

Contact Number (800) 247-2190 (970) 248-5056

Laron Gaines Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Donna Coleman-Fulk Regina Ratley Customer Service Customer Service Customer Service Center Customer Service Center Pam Stephenson Laura Sarle See Designated Group Puritan Life Gerber Life Insurance Idealife Insurance Company Lincoln Heritage Life PrincipalLifeInsurance Royal Neighbors of America Shenandoah Life Insurance State Mutual Insurance Sterling Investors Life KSKJ Life Central States Indemnity Co. of Omaha

(313) 664-7123 (972) 529-5085 (800) 247-2190 (800) 247-2190 (800) 247-2190 (800) 247-2190 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (336) 714-2910 (256) 532-2786 (888) 762-2189 (888) 762-2189 (800) 991-7392 (800) 991-7392 (919) 765-4379 (801) 579-3464 (866) 398-9305 (800) 838-0080 (866) 398-9310 (888) 586-8810 (800) 447-4701 (877) 815-8877 (866) 322-2856 (877) 872-5500 (877) 604-5240 (866) 671-5755 (855) 664-5517

30276

UNIFIED LIFE INSURANCE COMPANY

(877) 807-2143

30276

AMERICO FINANCIAL LIFE AND ANNUITY INSURANCE

(877) 212-2346

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner AMERICAN ENTERPRISE - WIA AMERICAN ENTERPRISE - WIB AMERICAN ENTERPRISE - A AMERICAN ENTERPRISE - B ASSURED LIFE ASSOCIATION TUFTS INSURANCE COMPANY ARKANSAS BCBS GERBER LIFE INS. CO. STANDARD LIFE AND ACCIDENT INS. UNITED NATIONAL LIFE INSURANCE COMPANY UNITED NATIONAL LIFE INSURANCE COMPANY BLUE CROSS OF CALIFORNIA BLUE CROSS OF COLORADO BLUE CROSS OF GEORGIA BLUE CROSS OF NEVADA BLUE CROSS OF WISCONSIN NEW ERA LIFE INS. CO. - MEDIGAP BLUE SHIELD OF CALIFORNIA PRIORITY HEALTH CT PINPE TRADES HEALTH GOVERNMENT PERSONNEL MUTUAL LIFE COLUMBIAN MUTUAL LIFE INSURANCE AULTCARE HARVARD PILGRIM HEALTH CARE, INC. BLUE CROSS BLUE SHIELD OF WNY GEISINGER HP/GOLD MEDICARE COLONIAL PENN LIFE INSURANCE CO. BCBS OF ALABAMA HEALTH FIRST INSURANCE CAPITAL DISTRICT PHYSICIANS HARVARD PILGRIM HEALTH CARE, INC. PBA INC. BLUE CROSS BLUE SHIELD OF GA UNIVERSAL FIDELITY LIFE INS. CO. OLYMPIC HEALTH MANAGEMENT SYSTEM GUARANTEE TRUST LIFE INS. CO. GUARANTEE TRUST LIFE INS. CO. GUARANTEE TRUST LIFE INS. CO. NATIONAL GUARDIAN LIFE INS. CO. NATIONAL GUARDIAN LIFE INS. CO. NATIONAL GUARDIAN LIFE INS. CO. MEMBERS HEALTH INSURANCE CO. Updated: 03/31/2016

Identification Number(s) 30277 30278 30279 30280 30281 30283 30285 30289 30291 30292 30293 30294 30295 30296 30297 30298 30299 30302 30305 30307 30308 30309 30313 30317 30319 30323 30326 30327 30328 30329 30330 30331 30332 30333 30335 30337 30338 30339 30340 30341 30342 30343

Customer Contact Customer Service Customer Service Customer Service Customer Service Customer Service EDI Operations Angela Winston Customer Service Jill Davis Mark Pytel Mark Pytel Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Annie Pressley-Mitchell Isabel Gonzalez Tammy Rutters Carol Nowak Stephanie Doyle Customer Service Customer Service Ty Pruette Michael Comerford Melissa Deboth Joanne Minium Customer Service Customer Service Angie Vazquez Kerri Petersen Michael Comerford Kathy Carpenter Lora Tincher Becky Morris Wendi Western Mark Pytel Mark Pytel Mark Pytel Mark Pytel Mark Pytel Mark Pytel Geri Cayce

Contact Number (888) 755-3064 (888) 755-3064 (888) 755-3064 (888) 755-3064 (877) 223-4244 (617) 972-9400 (501) 210-2074 (877) 656-5424 (281) 538-4890 (847) 904-5375 (847) 904-5375 (404) 848-2185 (404) 848-2185 (404) 848-2185 (404) 848-2185 (404) 848-2185 (281) 368-7108 (530) 351-6109 (616) 575-4914 (856) 910-9099 (866) 865-7631 (866) 703-7223 (330) 363-4234 (617) 509-1411 (716) 887-8443 (570) 271-5555 (800) 621-3724 (205) 988-2200 (321) 434-4206 (518) 641-3820 (617) 509-1411 (630) 655-3755 (502) 310-9374 (800) 366-8354 (360) 392-9465 (847) 904-5375 (847) 904-5375 (847) 904-5375 (847) 904-5375 (847) 904-5375 (847) 904-5375 (931) 560-0041

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner LOYAL AMERICAN LIFE INSURANCE CO. AVERA HEALTH PLANS, INC. NCSCBF HEALTH CARE SERVICE CORPORATION HEALTH CARE SERVICE CORPORATION SENTINEL SECURITY LIFE INS. CO SECURE ADMINISTRATIVE SOLUTIONS LOYAL CHRISTIAN BENEFIT ASSOC. INDIVIDUAL ASSURANCE COMPANY HOMETOWN HEALTH SENIOR CARE PLUS GREEK CATHOLIC UNION WELLMARK BCBS OF SD MEDIGAP WELLMARK BCBS OF SD MEDIGAP TN RURAL HEALTH IMPROVEMENT ASS. QUALCHOICE LIFE HEALTH INSURANCE BCBS of Minnesota BCBS of Minnesota SISCO MERCER HEALTH & BENEFITS ADM LLC

Updated: 03/31/2016

Identification Number(s) 30344 30352 30353 30354 30355 30357 30358 30359 30360 30362 30363 30364 30365 30367 30368 30369 30370 30371 30374

Customer Contact Customer Service Karen Mikuska Lori Eslinger Customer Service Customer Service Linda Jonides Linda Jonides Laura Sarle Laura Sarle Ryan Hopkins Laura Sarle Wellmark BCBS Wellmark BCBS Geri Cayce Ashley Matthews Customer Service Customer Service Kara Kessler Dee Green

Contact Number (866) 459-4272 (605) 322-4502 (715) 835-3174 (866) 459-4272 (888) 762-2189 (801) 478-4041 (801) 478-4041 (801) 579-3464 (801) 579-3464 (775) 982-3239 (801) 579-3464 (800) 587-9242 (800) 587-9242 (931) 560-3097 (501) 228-7111 (800) 531-6686 (800) 531-6686 (563) 587-5204 (515) 365-6374

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner BANKERS LIFE AND CASUALTY GLOBE LIFE & ACCIDENTAL INS CO AMERICAN INCOME LIFE INSURANCE FIRST UNITED AMERICAN LIFE INS UNITED AMERICAN INSURANCE CO LIBERTY NATIONAL LIFE INSURANCE GOLDEN RULE INSURANCE CO ACTUARIAL MANAGEMENT RESOURCES SHELTER LIFE INSURANCE COMPANY TRICARE FOR LIFE (ADMINISTERED BY WISCONSIN PHYSICIAN SERVICES) - TRICARE HORIZON BCBS OF NJ - OTHER/FEHBP BCBS OF MICHIGAN - FEP BCBS OF ALABAMA - OTHER BCBS OF SC HIGHMARK, INC. - OTHER LIMITED B & DMERC HIGHMARK, INC. - OTHER PART A ONLY HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - OTHER HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - OTHER HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- OTHER CBA INC. NATIONAL ASSOCIATION OF LETTER CARRIERS HEALTH PLAN - OTHER BLUE CROSS AND BLUE OF MISSISSIPPI - OTHER/FEHBP BLUE CROSS OF NORTHEASTERN PA - OTHER (LIMITED PART A ONLY) BLUE CROSS OF NORTHEASTERN PA - OTHER BLUE CROSS OF NORTHEASTERN PA - OTHER BLUE CROSS OF NORTHEASTERN PA - OTHER (LIMITED PART A ONLY) TRIPLE S, INC. - OTHER BCBS OF ALABAMA - OTHER BCBS OF NORTH DAKOTA (OTHER) HAWAII MEDICAL SERVICES ASSOCIATION -OTHER HAWAII MEDICAL SERVICES ASSOCIATION -OTHER BCBS OF TENNESSEE - OTHER HAWAII MEDICAL SERVICES ASSOCIATION -OTHER BLUE CROSS AND BLUE SHIELD OF MINNESOTA - OTHER KANSAS BCBS - OTHER/FEHBP ADMINISTRATIVE SERVICES ONLY, INC. OTHER KPS HEALTH PLANS - OTHER ANTHEM BCBS FEP OF IN - OTHER

Updated: 03/31/2016

Identification Number(s) 55000 55001 55002 55003 55004 55005 55009 55010 55015 60000 80003 80004 80005 80006 80007 80008 80009 80011 80012 80013 80015 80016 80017 80018 80019 80020 80021 80022 80023 80024 80025 80026 80027 80029 80030 80031 80032 80033

Customer Contact Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service James Anderson Donna Coleman-Fulk Carla Lind Customer Service Customer Service Customer Service Customer Service Cynthia Lagatore Customer Service Customer Service Customer Service Customer Service Customer Service Carol Lea Stephanie Smith Customer Service Carol Stitzer Carol Stitzer Carol Stitzer Carol Stitzer Jeannette Irizarry Velez Customer Service Shelly Stalpes Debbie Ruiz Amy Jampel Venessa Marsh George Yamada MN only Customer Service Laura Lombardo Teresa Hiagh-Braget Lora Tincher

Contact Number (800) 621-3724 (972) 529-5085 (972) 529-5085 (972) 529-5085 (972) 529-5085 (972) 529-5085 (317) 715-7200 (336) 714-2910 (573) 214-4128 (866) 773-0404 (800) 624-1110 (800) 482-3600 (205) 988-2200 (803) 264-3326 (800) 345-3806 (800) 345-3806 (888) 762-2189 (888) 762-2189 (888) 762-2189 (802) 846-8038 (703) 729-4677 ext. 8235 (800) 932-7724 (570) 200-4540 (570) 200-4540 (570) 200-4540 (570) 200-4540 (787) 749-4949 (205) 988-2200 (701) 282-1476 (808) 952-7636 (808) 948-6597 (423) 535-4930 (808) 948-5534 (800) 531-6686 (800) 432-3990 (516) 394-9434 (360) 478-2635 (502) 310-9374

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner ANTHEM BCBS FEP OF CO - OTHER ANTHEM BCBS FEP OF KY - OTHER ANTHEM BCBS FEP OF CT - OTHER ANTHEM BCBS FEP OF OH - OTHER ANTHEM BCBS FEP OF NV - OTHER ANTHEM BCBS FEP OF VA - OTHER ANTHEM BCBS FEP OF ME - OTHER ANTHEM BCBS FEP OF NH - OTHER STIRLING & STIRLING - OTHER BCBS OF LOUISIANA - OTHER AULTCARE - OTHER BLUE SHIELD OF CALIFORNIA - OTHER BLUE CROSS BLUE SHIELD OF NC CAPITAL BLUE CROSS- OTHER BLUE CROSS BLUE SHIELD OF WNY BLUE CROSS BLUE SHIELD OF WNY GOVERNMENT EMPLOYEES HOSPITAL ASSOCIATION (GEHA) - OTHER EMPIRE BCBS- OTHER/FEHBP EMPIRE BCBS- OTHER/FEHBP BLUE CROSS AND BLUE SHIELD OF DELAWARE - OTHER SPECIAL AGENTS MUTUAL BENEFIT ASSOC. (SAMBA) - OTHER BCBS OF ARIZONA - OTHER BCBS OF WYOMING - OTHER (LIMITED TO PART B) BCBS OF NORTH DAKOTA ARKANSAS BCBS FEP - OTHER/FEHBP USAABLE ADMINISTRATORS - OTHER BLUE ADVANTAGE ADMIN OF ARKANSAS - OTHER USAABLE LIFE - OTHER NORTHWEST ADMINISTRATORS - OTHER BC OF IDAHO- OTHER BC OF IDAHO- OTHER APWU HEALTH PLAN - OTHER HIGHMARK WEST VIRGINIA HIGHMARK WEST VIRGINIA HIGHMARK WEST VIRGINIA HIGHMARK WEST VIRGINIA CHCS SERVICES, INC. - OTHER, FEHBP (A ONLY) CHCS SERVICES, INC. - OTHER, FEHBP CHCS SERVICES, INC. - OTHER, FEHBP (A ONLY) CHCS SERVICES, INC. - OTHER, FEHBP BCBS OF MASS KLAIS & COMPANY - OTHER NATIONAL CAPITAL ADMINISTRATIVE SERVICES (NCAS) - OTHER Updated: 03/31/2016

Identification Number(s) 80034 80035 80036 80037 80038 80039 80040 80041 80042 80043 80044 80045 80046 80047 80048 80050 80054 80055 80056 80057 80058 80059 80061 80062 80065 80066 80067 80068 80070 80073 80074 80075 80076 80076 80077 80077 80078 80079 80080 80081 80086 80089 80090

Customer Contact Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Monica Strong Customer Service Ty Pruett Tammy Rutters Pam Stephenson Nancy Herman Melissa Deboth Melissa Deboth Daryl Evans Lora Tincher Annie Pressley-Mitchell Customer Service Customer Service Zoila Buruato Amber Zowada Shelly Stalpes Shawana Coleman Martha Campbell Martha Campbell Martha Campbell Danielle Brenner Laurie Warren Laurie Warren Loretta Demby Member Customer Service Provider Customer Service Member Customer Service Provider Customer Service Insurance Service Service Insurance Service Service Insurance Service Service Insurance Service Service Customer Service Customer Service Customer Service

Contact Number (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (203) 647-0630 (800) 392-4089 (330) 363-4234 (530) 351-6109 (919) 765-4379 (717) 541-6274 (716) 887-8443 (716) 887-8443 (816) 257-5000 (502) 310-9374 (404) 848-2185 (302) 429-0260 (800) 638-6589 (602) 864-4814 (307) 432-2743 (701) 282-1476 (501) 378-2506 (501) 378-2958 (501) 378-2958 (501) 378-2958 (206) 726-3230 (208) 331-7641 (208) 331-7641 (410) 424-1544 (888) 809-9121 (800) 543-7822 (888) 809-9121 (800) 543-7822 (850) 435-8000 (850) 435-8000 (850) 435-8000 (850) 435-8000 (800) 433-7766 (800) 331-1096 (800) 873-5781

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS HEALTH SCOPE BENEFITS - OTHER BCBS OF KANSAS CITY BENESYS - OTHER BENESYS - OTHER BCBS OF RHODE ISLAND PRIORITY HEALTH - OTHER HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF ILLINOIS - OTHER HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF NEW MEXICO - OTHER HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF TEXAS- OTHER COVENTRY PERSONAL CARE INSURANCE OF ILLINOIS, INC. COMMUNITY FIRST HEALTH PLANS - OTHER EXCELLUS HEALTH PLAN (INCLUDING BCBS OF UTICA, SYRACUSE, & ROCHESTER) - OTHER NORTHWEST ADMINISTRATORS, INC. ROCKY MOUNTAIN COVENTRY GROUP HEALTH PLAN, INC. - OTHER COVENTRY HEALTH CARE (FIRST HEALTH GROUP) COVENTRY HEALTH CARE OF NEBRASKA - OTHER COVENTRY HEALTH CARE OF IOWA - OTHER COVENTRY HEALTH CARE (FIRST HEALTH GROUP) HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF OK (FEP A ONLY) HEALTH CARE SERVICES CORPORATION (HCSC) BCBS OF OK (FEP B ONLY) BCBS OF WYOMING COVENTRY HEALTH CARE (HEALTHAMERICA OF PENNSYLVANIA, INC.) COVENTRY HEALTH CARE OF LOUISIANA COVENTRY HEALTH CARE OF GEORGIA, INC. COVENTRY HEALTH CARE (CARELINK HEALTH PLAN, INC.) Updated: 03/31/2016

Identification Number(s) 80091 80091 80091 80091 80091 80091 80091 80091 80091 80091 80091 80091 80091 80091 80091 80091 80091 80091 80092 80093 80094 80096 80098 80102 80103 80104 80105 80110 80113 80114 80116 80118 80119 80120 80121 80122 80123 80124 80128 80129 80131 80132 80133

Customer Contact WC Bradley Neff Company ENPRO CAC Auto Systems Phillips KRAFT Emerson Svc Ctr CNAF Southwest Electric American Greetings Svc Ctr Whirlpool Svc Ctr Ball Corporation Alcoa Svc Ctr Adams Loews/Lorillard Goodrich See Designated Group Kathy Currey Customer Service Customer Service Customer Service Carol Nowark Customer Service Customer Service Customer Service Customer Service Rose Allen Jill Kohler Danielle Brenner Kris Malean Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service

Contact Number (877) 883-5352 (877) 624-1325 (877) 616-7421 (877) 240-0139 (877) 240-0136 (877) 226-2051 (800) 972-3025 (800) 913-9982 (800) 892-7182 (800) 851-5644 (800) 827-7026 (800) 660-6212 (800) 493-9552 (800) 426-3070 (800) 314-5366 (800) 262-9247 (800) 262-2066 (816) 395-3877 (800) 572-2525 (800) 572-2525 (800) 267-0439 (616) 575-4914 (888) 762-2189 (888) 762-2189 (888) 762-2189 (302) 203-6570 (210) 358-6192 (315) 272-1210 (206) 726-3230 (970) 248-5056 (302) 203-6570 (302) 203-6570 (302) 203-6570 (302) 203-6570 (302) 203-6570 (888) 762-2189 (888) 762-2189 (888) 762-2189 (302) 203-6570 (302) 203-6570 (302) 203-6570 (302) 203-6570

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner COVENTRY HEALTH CARE (SOUTHERN HEALTH SERVICES, INC.) COVENTRY HEALTH CARE OF DELAWARE, INC. COVENTRY HEALTH CARE (WELLPATH SELECT, INC.) C.L. FRATES AND COMPANY ANTHEM BCBS FEP OF CA - OTHER HEALTH SMART BENEFIT SOLUTIONS BCBS MO FEP BCBS WI FEP BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MINNESOTA PRAIRIE STATES ENTERPRISES, INC. INNOVATIVE HEALTHWARE SERVICES BENEFITS MANAGEMENT GROUP, INC. LIPMAN INSURANCE ADMINISTRATORS, INC. CDS GROUP HEALTH GROUP AND PENSION ADMINISTRATORS, INC. WELFARE AND PENSION ADMIN SERVICE MAGNACARE ADMIN SERVICES SHASTA ADMINISTRATIVE SERVICES COVENTRY HEALTH CARE (FEDRAL PLAN) PREMERA BS FEP/EASTERN WA PREMERA BC FEP/WASHINGTON PREMERA BCBS FEP/ALASKA PREMERA BCBS FEP/ALASKA GROUP ADMINSITRATORS, LTD. AMERIBEN KAISER FOUNDATION HEALTH PLAN BENESYS, INC BCBS OF NEBRASKA INDEPENDENCE BLUE CROSS BCBS OF NEBRASKA KEMPTON COMPANY BENESYS, INC GILSBAR, INC. GILSBAR, INC. Updated: 03/31/2016

Identification Number(s) 80134 80135 80136 80138 80140 80142 80145 80146 80147 80148 80149 80150 80151 80152 80153 80154 80155 80156 80158 80160 80161 80162 80163 80165 80166 80181 80187 80189 80190 80191 80192 80193 80194 80195 80196 80197 80198 80199 80202 80204 80209 80210

Customer Contact Customer Service Customer Service Customer Service Rick Franklin Annie Pressley-Mitchell John Campbell Lora Tincher Lora Tincher Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Kathie Horness Jessica Picarde Lisa Frasco Sylvia Sanchez Customer Service Department Customer Service Heidi Campbell Customer Service Center Sheryl Petrakis-Wood Customer Service Customer Service Customer Service Customer Service Customer Service Kim Ufkes Carrie Hatch Phyllis Tennant

Contact Number (302) 203-6570 (302) 203-6570 (302) 203-6570 (405) 290-5744 (404) 848-2185 (214) 574-3582 (502) 310-9374 (502) 310-9374 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (800) 531-6686 (920) 451-7020 (410) 349-3222 (630) 230-3911 (510) 796-4676 (800) 455-4236 (972) 238-7900 (206) 695-0985 (888) 352-6465 (541) 504-2772 (800) 410-7778 (800) 722-1471 (800) 722-1471 (800) 722-1471 (800) 722-1471 (847) 519-1880 (208) 947-9229 (440) 268-2741

Customer Service Center Sharelle Bond Customer Service Center Dwight Berry

(800) 223-5584 (215) 241-2000 (800) 223-5584 (405) 556-5125

Customer Contact Center Customer Contact Center

(888) 472-4352 (888) 472-4352

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner WESTERN GROWERS ASSURANCE TRUST PINNACLE CLAIMS MANAGEMENT, INC. CHAMPVA-VA HEALTH ADMIN CTR MERITAIN HEALTH INFORMED, LLC ZENITH ADMINISTRATORS, U054 COVENTRY- CHC OF FLORIDA ZENITH ADMINISTRATORS, K630 ZENITH ADMINISTRATORS, B0131 ZENITH ADMINISTRATORS, A0033 ZENITH ADMINISTRATORS, A0001 ZENITH ADMINISTRATORS, U614 ZENITH ADMINISTRATORS, U320 COOPERATIVE BENEFIT ADMIN/NRECA ZENITH AMERICAN SOLUTIONS, N011 ZENITH AMERICAN SOLUTIONS, N026 ZENITH AMERICAN SOLUTIONS, N589 ZENITH AMERICAN SOLUTIONS, N115 ALLIED BENEFIT SYSTEMS, INC. AMA INSURANCE AGENCY, INC. HEALTHCOMP ZENITH AMERICAN SOLUTIONS, K639 ZENITH AMERICAN SOLUTIONS, K297 ZENITH AMERICAN SOLUTIONS, H0185 CAREFIRST ADMINISTRATORS BCBS GA FEP ZENITH AMERICAN SOLUTIONS, N351 HEALTH PLANS INC. SCOTT & WHITE HEALTH PLAN CHCS SERVICES INC CHCS SERVICES INC CHCS SERVICES INC CHCS SERVICES INC CHCS SERVICES INC CHCS SERVICES INC CHCS SERVICES INC HEALTH CARE SERVICE CORPORATION HEALTH CARE SERVICE CORPORATION LINE CONTRUCTION BENEFIT FUND ASSOCIATED THIRD PARTY ADMIN APEX HEALTH SOLUTIONS EMPLOYEE BENEFIT MGMT SERVICES Updated: 03/31/2016

Identification Number(s) 80212 80213 80214 80216 80217 80219 80220 80223 80224 80226 80228 80230 80231 80232 80233 80235 80238 80239 80240 80241 80242 80244 80245 80246 80248 80250 80251 80252 80253 80254 80255 80256 80257 80258 80259 80260 80261 80262 80264 80267 80268 80269

Customer Contact Lara Hassan Lara Hassan HAC Customer Service Center Customer Service George govatos Jr. Tracy Weston Customer Service Irene Newman Kathleen Linzmeier Rosie Bailey Rosie Bailey Lisa Pasby Lisa Pasby Mikki McGuire Trini Caoili Trini Caoili Trini Caoili Trini Caoili Terry Jones Customer Service Charles Johnson Karen May Karen May Kathy Leonard Fred Ellerbe Annie Pressley-Mitchell Becky Placek Chris Parr Noel Rivas Insurance Service Center Insurance Service Center Insurance Service Center Insurance Service Center Insurance Service Center Insurance Service Center Insurance Service Center Blue Cross Blue Shield Blue Cross Blue Shield Customer Service Marilyn Haynes Betsy Gossard Lisa Rel

Contact Number (949) 885-2309 (949) 885-2309 (800) 733-8387 (800) 925-2272 (410) 972-2028 (206) 352-9751 (866) 847-8235 (317) 248-3272 (608) 846-1742 (651) 256-1786 (651) 256-1786 (509) 532-2246 (509) 532-2247 (402) 483-9268 (415) 536-8290 (415) 536-8290 (415) 536-8290 (415) 536-8290 (312) 906-8080 (800) 458-5736 (559) 499-2450 (414) 476-3742 (414) 476-3742 (314) 209-3110 (877) 889-2478 (404) 848-2185 (415) 536-8268 (508) 475-6104 (254) 298-3233 (850) 435-8000 (850) 435-8000 (850) 435-8000 (850) 435-8000 (850) 435-8000 (850) 435-8000 (850) 435-8000 (888) 762-2189 (888) 762-2189 (800) 323-7268 (925) 288-4017 (330) 996-8400 (406) 245-3575

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner HEALTH PLAN SYSTEMS SERVICES COR STONER AND ASSOCIATES QUALCHOICE QCA HEALTH PLAN INC

Updated: 03/31/2016

Identification Number(s) 80270 80272 80273

Customer Contact Satish Kurian Linda Sites Ashley Matthews

Contact Number (732) 362-2011 (304) 525-0331 (501) 228-7111

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner ANTHEM CENTRAL - FACETS ANTHEM CENTRAL - FACETS ANTHEM BCBS VIRGINIA ANTHEM BCBS VIRGINIA ANTHEM BCBS VIRGINIA ANTHEM BCBS VIRGINIA EMPIRE BLUE CROSS BLUE SHIELD I EMPIRE BLUE CROSS BLUE SHIELD II EMPIRE BLUE CROSS BLUE SHIELD II EMPIRE BLUE CROSS BLUE SHIELD II EMPIRE BLUE CROSS BLUE SHIELD I EMPIRE BLUE CROSS BLUE SHIELD I EMPIRE BLUE CROSS BLUE SHIELD I ANTHEM BCBS CONNECTICUT ANTHEM BCBS NEW HAMPSHIRE ANTHEM BCBS MAINE ANTHEM BCBS MAINE ANTHEM BCBS NEW HAMPSHIRE ANTHEM BCBS CONNECTICUT ANTHEM BCBS NORTHEAST REGION ANTHEM BCBS NORTHEAST - PART B ANTHEM NATIONAL BCBS OHIO CTRL ANTHEM NATIONAL BCBS KY CONTROL ANTHEM NATIONAL BCBS IN CONTROL BLUE CROSS OF CALIFORNIA UNICARE LIFE & HEALTH INSURANCE BLUE CROSS OF CALIFORNIA UNICARE LIFE & HEALTH INSURANCE BLUE CROSS BLUE SHIELD OF WI ANTHEM BCBS OF NEVADA ANTHEM BCBS OF COLORADO ANTHEM BCBS OF NEVADA ANTHEM BCBS OF COLORADO ANTHEM FEP INDIANA ANTHEM FEP COLORADO ANTHEM FEP KENTUCKY ANTHEM FEP CONNECTICUT ANTHEM FEP OHIO ANTHEM FEP NEVADA ANTHEM FEP VIRGINIA

Updated: 03/31/2016

Identification Number(s) 88005 88007 88009 88010 88011 88012 88013 88014 88015 88016 88017 88018 88019 88020 88021 88022 88023 88024 88025 88026 88027 88033 88036 88038 88039 88040 88041 88042 88043 88044 88045 88046 88047 88048 88049 88050 88051 88052 88053 88054

Customer Contact Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher

Contact Number (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner ANTHEM FEP MAINE ANTHEM FEP NEW HAMPSHIRE ANTHEM FEP CALIFORNIA BCBS MO FEP BCBS WI FEP NALC HEALTH BENEFIT PLAN BCBS OF ALABAMA BCBS OF ALABAMA BCBS OF ALABAMA MUTUAL OF OMAHA INSURANCE COMP BLUE SHIELD OF CALIFORNIA BLUE SHIELD OF CALIFORNIA BLUE SHIELD OF CALIFORNIA AR FEDERAL EMPLOYEE PROGRAM USAABLE ADMINISTRATORS BLUE ADVANTAGE ADMIN OF ARKANSAS USABLE LIFE ARKANSAS BCBS ARKANSAS BCBS PHYSICIANS MUTUAL INS.CO CORESOURCE, INC NATIONAL CAPITAL ADMIN SVCS OLD SURETY LIFE INSURANCE COMP THRIVENT FINANCIAL FOR LUTHERANS THRIVENT FINANCIAL FOR LUTHERANS ASURIS REGENCE BCBS OF OREGON REGENCE BLUESHIELD OF IDAHO REGENCE BLUESHIELD OF UTAH REGENCE BLUESHIELD NORTH AMERICAN INSURANCE COMPANY PEKIN LIFE INSURANCE COMPANY PIPE FITTERS WELFARE FUND HEALTH ADVANTAGE MEDICO WI PART A MEDICO WI PART B MEDICO WI PART A MEDICO WI PART B AMERICAN ENTERPRISE - WIA AMERICAN ENTERPRISE - WIB AMERICAN ENTERPRISE - A AMERICAN ENTERPRISE - B Updated: 03/31/2016

Identification Number(s) 88055 88057 88058 88059 88060 88061 88062 88063 88064 88067 88068 88069 88070 88073 88074 88075 88076 88078 88079 88081 88084 88085 88086 88087 88088 88092 88098 88105 88110 88117 88121 88122 88123 88124 88125 88126 88127 88128 88129 88130 88131 88132

Customer Contact Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher David Hardesty Customer Service Customer Service Customer Service Customer Service Tammy Rutters Tammy Rutters Tammy Rutters Shawana Coleman Martha Campbell Martha Campbell Martha Campbell Angela Winston Angela Winston Alan Schoening Kurt Henry Fred Ellerbe

Contact Number (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (703) 729-4677 (205) 988-2200 (205) 988-2200 (205) 988-2200 (800) 775-1000 (530) 351-6109 (530) 351-6109 (530) 351-6109 (501) 378-2506 (501) 378-2958 (501) 378-2958 (501) 378-2958 (501) 210-2074 (501) 210-2074 (402) 633-2785 (800) 354-8233 (800) 888-6227

Rebecca Freeman Rebecca Freeman Rebecca Thorn Rebecca Thorn Rebecca Thorn Rebecca Thorn Rebecca Thorn Julie Tauber Customer Service

(920) 628-2329 (920) 628-2329 (503) 375-4341 (503) 375-4341 (503) 375-4341 (503) 375-4341 (503) 375-4341 (800) 627-4282 (800) 322-0160

Dee McKee Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service

(501) 212-8520 (800) 247-2190 (800) 247-2190 (800) 247-2190 (800) 247-2190 (888) 755-3064 (888) 755-3064 (888) 755-3064 (888) 755-3064

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner AMERICAN REPUBLIC INSURANCE CO AMERICAN REPUBLIC INSURANCE CO AMERICAN REPUBLIC INSURANCE CO AMERICAN REPUBLIC INSURANCE CO WORLD INSURANCE COMPANY INSURANCE ADMIN SOLUTIONS, LLC INSURANCE ADMIN SOLUTIONS, LLC INSURANCE ADMIN SOLUTIONS, LLC INSURANCE ADMIN SOLUTIONS, LLC INSURANCE ADMIN SOLUTIONS, LLC INSURANCE ADMIN SOLUTIONS, LLC INSURANCE ADMIN SOLUTIONS, LLC INSURANCE ADMIN SOLUTIONS, LLC INSURANCE ADMIN SOLUTIONS, LLC INSURANCE ADMIN SOLUTIONS, LLC BCBS OF TENNESSEE-SUPPLEMENTAL BCBS OF TENNESSEE-MEDIGAP BCBS OF TENNESSEE-OTHER CONSECO SERVICES, LLC G.M.P. - EMPLOYERS RETIREE TRUST PA EMPLOYEES BENEFIT TRUST FUND WOODMEN OF THE WORLD LOYAL AMERICAN LIFE INSURANCE CO. CONSECO SERVICES - COLONIAL PENN NGS AMERICAN, INC BANKERS LIFE AND CASUALTY STATE FARM AUTOMOBILE INS. CO. BLUE CROSS OF CALIFORNIA BLUE CROSS OF COLORADO BLUE CROSS OF GEORGIA BLUE CROSS OF NEVADA BLUE CROSS OF WISCONSIN GILSBAR, INC. GILSBAR, INC. COLONIAL PENN LIFE INSURANCE CO. BCBS OF ALABAMA BLUE CROSS/SHIELD OF GA KC SUP BLUE CROSS/SHIELD OF GA BLUE CROSS BLUE SHIELD OF GA KCSUP UNIVERSAL FIDELITY LIFE INS. CO.

Updated: 03/31/2016

Identification Number(s) 88133 88134 88135 88136 88137 88150 88150 88150 88150 88150 88150 88150 88150 88150 88150 88160 88162 88163 88174 88209 88210 88219 88221 88224 88225 88227 88228 88229 88230 88231 88232 88233 88240 88241 88248 88249 88250 88251 88252 88253

Customer Contact Customer Service Customer Service Customer Service Customer Service World Insurance Customer Service Lincoln Heritage Life State Mutual Insurance Royal Neighbors of America Sterling Investors Life Idealife Insurance Company Puritan Life Shenandoah Life Insurance Gerber Life Insurance PrincipalLifeInsurance KSKJ Life Customer Service Customer Service Customer Service Customer Service Amy Thomas Dave Walton Customer Service Customer Service Customer Service Customer Service Customer Service Customer Service Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Customer Contact Center Customer Contact Center Customer Service Customer Service Lora Tincher Lora Tincher Lora Tincher Becky Morris

Contact Number (800) 247-2190 (800) 247-2190 (800) 247-2190 (800) 247-2190 (800) 786-5443 (888) 586-8810 (877) 872-5500 (877) 815-8877 (877) 604-5240 (866) 398-9310 (866) 398-9305 (866) 322-2856 (800) 838-0080 (800) 447-4701 (866) 671-5755 (800) 553-8158 (800) 553-8158 (800) 553-8158 (800) 621-3724 (239) 936-6242 (717) 565-7410 (877) 223-4244 (866) 459-4272 (800) 523-4000 (800) 521-1555 (800) 621-3724 (866) 855-1212 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (888) 472-4352 (888) 472-4352 (800) 621-3724 (205) 988-2200 (502) 310-9374 (502) 310-9374 (502) 310-9374 (800) 366-5354

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) Trading Partner CARE FIRST ADMINISTRATORS NATIONAL BCBS GEORGIA BCBS OF FEP LOYAL AMERICAN LIFE INSURANCE CO. UNITEDHEALTH GROUP ASSOCIATED THIRD PARTY ADMIN NEW YORK ISG NEVADA ISG MAINE ISG WISCONSIN ISG KENTUCKY ISG VIRGINIA ISG NEW HAMPSHIRE ISG MISSOURI ISG OHIO ISG CALIFORNIA ISG COLORADO ISG CONNECTICUT ISG INDIANA ISG CONNECTICUT WGS INDIANA WGS KENTUCKY WGS MISSOURI WGS NEW YORK WGS OHIO WGS VIRGINIS WGS WISCONSIN WGS EMPLOYEE BENEFIT MGMT SERVICES QUALCHOICE QCA HEALTH PLAN INC QUALCHOICE LIFE HEALTH INSURANCE UPREHS CONSOLIDATED ASSOC. OF RR EMP. SCOTT & WHITE HEALTH PLAN C&O EMPLOYEES HOSPITAL ASSOC. WABASH MEMORIAL HOSPITAL ASSOC. HEALTHSMART BENEFITS SOLUTIONS MEDICAL ASSOC HEALTH PLAN INC. ROCKY MOUNTAIN HEALTH MAINTENANCE

Updated: 03/31/2016

Identification Number(s) 88254 88255 88256 88258 88260 88261 88262 88263 88264 88265 88266 88267 88268 88269 88270 88271 88272 88273 88274 88275 88276 88277 88279 88281 88282 88283 88284 88285 88289 88290 89001 89002 89003 89004 89005 89006 89009 89010

Customer Contact Fred Ellerbe Lora Tincher Lora Tincher Customer Service Customer Service Marilyn Haynes Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lora Tincher Lisa Rel Ashley Matthews Ashley Matthews Deann Benson Kathy Hampton Brenda Lee Anna Brooks Debby Kunze Kathy Hansen Laura Boge Marci O'Gara

Contact Number (877) 889-2478 (502) 310-9374 (502) 310-9374 (866) 459-4272 (800) 523-5800 (925) 288-4017 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (502) 310-9374 (406) 245-3575 (501) 228-7111 (501) 228-7111 (801) 595-4309 (254) 773-1330 (254) 298-3391 (540) 862-5728 (217) 429-5246 (214) 574-3509 (563) 556-8070 (970) 248-5137

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) State Medicaid Agencies Trading Partner MARYLAND DEPT OF HEALTH & MENTAL HYGIENE - MEDICAID MASSACHUSETTS STATE MEDICAID MINNESOTA DEPT. OF HUMAN SERVICES - MEDICAID OREGON DEPT OF HUMAN SVCS OREGON DEPT OF HUMAN SVCS NEW JERSEY MEDICAID VA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES(MEDICAID) ILLINOIS HEALTHCARE AND FAMILY SERVICES RHODE ISLAND DEPARTMENT OF HUMAN SERVICES ALABAMA MEDICAID AGENCY NORTH DAKOTA DEPARTMENT OF HUMAN & MEDICAL SERVICES DIVISION OF MEDICAID, STATE OF MISSISSIPPI KANSAS DIRECTOR OF HEALTH POLICY AND FINANCE FLORIDA MEDICAID, AGENCY FOR HEALTHCARE ADMINISTRATION ARKANSAS MEDICAID PROGRAM IDAHO DEPARTMENT OF HEALTH & WELFARE MEDICAID DIVISION SOUTH DAKOTA MEDICAID IOWA DEPARTMENT OF HUMAN SERVICES STATE OF ALASKA MEDICAID PROGRAM STATE OF CONNECTICUT, DEPT OF SOCIAL SERVICES WV MMIS - UNISYS OKLAHOMA HEALTH CARE AUTHORITY UTAH DEPARTMENT OF HEALTH DHHS, STATE OF NEW HAMPSHIRE DHHS, STATE OF NEW HAMPSHIRE DHHS, STATE OF NEW HAMPSHIRE WISCONSIN MEDICAID- DIVISION OF HEALTH CARE FINANCING MO MEDICAID MO MEDICAID MO MEDICAID NEVADA-DHCFP COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE DELAWARE DEPARTMENT OF HEALTH & SOCIAL SERVICES DELAWARE DEPARTMENT OF HEALTH & SOCIAL SERVICES DELAWARE DEPARTMENT OF HEALTH & SOCIAL SERVICES OHIO DEPARTMENT OF JOB AND FAMILY SERVICES DEPARTMENT OF HEALTH AND HOSPITALS-LOUISIANA MEDICAID INDIANA OFFICE OF MEDICAID POLICY - MEDICAID VERMONT MEDICAID COLORADO DEPT OF HEALTH CARE POLICY & FINANCING COLORADO DEPT OF HEALTH CARE POLICY & FINANCING Updated: 03/31/2016

Identification Number(s) 70000 70001 70002 70005 70005 70006 70008 70009 70010 70011 70012 70014 70015 70016 70017 70018 70019 70020 70021 70022 70024 70025 70026 70027 70027 70027 70028 70029 70029 70029 70030 70031 70032 70032 70032 70033 70034 70035 70036 70037 70037

Customer Contact Janet Smith Customer Service Derik Newman Client Services Provider Services Reeshemah Trower Maryanne Paccione Steve Bradley Helen Vaughn Keith Thompson Michelle Adams Chris Bryan EDI Help Desk Daniel Gray Angelia Norris Phil Howard Lori Thompson Provider Services Linda Walsh Sandi Ouellette Ellen Charlebois Holly Rictor Purita Buck Provider Relations (NH) Provider Relations (outside) Recipient Services Katie Ploeser Technical Issuse Provider Billing Recipient Services Tammy Moffitt Customer Service Provider Relations (DE, MD) Provider RelationsOutside Customer Relations Jo Steinert Provider Relations Customer Service Provider Relations Client Support (within) Client Support (outside)

Contact Number (410) 767-5377 (800) 841-2900 (651) 431-2287 (800) 273-0557 (800) 336-6016 (609) 631-6663 (804) 225-2866 (217) 785-2867 (401) 784-3879 (334) 242-5248 (701) 328-4046 (601) 206-2977 (800) 933-6593 (850) 298-7034 (501) 374-6609 (208) 373-1318 (605) 773-3495 (800) 338-7909 (907) 334-2441 (860) 424-5216 (304) 348-3276 (405) 522-7939 (801) 538-6477 (800) 428-8303 (603) 224-1747 (800) 852-3345 ext. 4344 (608) 221-4746 (573) 635-3559 (573) 751-2896 (800) 392-2161 or (573) 751-6527 (775) 684-3623 (866) 542-3015 (800) 999-3371 (302) 454-7154 (800) 372-2022 (614) 387-1212 (800) 473-2783 (800) 577-1278 (802) 879-4450 (303) 866-3513 (800) 221-3943

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) State Medicaid Agencies Trading Partner COLORADO DEPT OF HEALTH CARE POLICY & FINANCING NEBRASKA HEALTH & HUMAN SERVICES - MEDICAID GEORGIA DEPT OF HEALTH NYS DEPARTMENT OF HEALTH NORTH CAROLINA - DEPT OF HEALTH AND HUMAN SERVICES NORTH CAROLINA - DEPT OF HEALTH AND HUMAN SERVICES BUREAU TENN CARE WYOMING - DEPT OF HEALTH WASHINGTON DC MEDICAID NEW MEXICO MEDICAL ASSISTANCE DIV HUMAN SERVICES DEPARTMENT TEXAS HEALTH AND HUMAN SERVICES CALIFORNIA - DEPT OF HEALTH SERVICES STATE OF MONTANA - DEPT OF PUBLIC HEALTH & HUMAN SERVICES STATE OF ARIZON MEDICAID (AHCCCS) STATE OF HAWAII MEDICAID (DHS MED-QUEST DIV) COMMONWEALTH OF KENTUCKY WASHINGTON MEDICAID MAINE DEPARTMENT OF HEALTH & HUMAN SERVICES OFFICE OF MAINECARE SERVICES COMMONWEALTH OF KENTUCKY OHANA HEALTH PLAN STATE OF MICHIGAN - MDCH KENTUCKY/WELLCARE KENTUCKY/CONVENTRY KENTUCKY/SPIRIT HEALTH PLAN NEW JERSEY DEPT. OF HUMAN SERVICES NEW JERSEY DEPT. OF HUMAN SERVICES NEW JERSEY DEPT. OF HUMAN SERVICES NEW JERSEY DEPT. OF HUMAN SERVICES KENTUCKY/HUMANA KENTUCKY/PHP NEW JERSEY DEPT. OF HUMAN SERVICES KENTUCKY/ANTHEM EXE. OFFICE HUMAN SRVS RINHP ARIZONA MEDICAID AHCCCS NJ DEPT. OF HUMAN SERVICES MOLINA HEALTHCARE OF OHIO AETNA BETTER HEALTH OF OHIO BUCKEYE COMMUNITY HEALTH PLAN CARESOURCE UNITED HEALTHCARE OF OHIO CALIFORNIA DEPT. OF HEALTH CARE WA STATE MEDICAID QUALITY PROJ Updated: 03/31/2016

Identification Number(s) 70037 70038 70039 70040 70042 70042 70043 70045 70047 70048 70051 70052 70053 70054 70055 70058 70059 70067 70068 70071 70073 70074 70075 70076 70077 70078 70079 70080 70083 70084 70085 70086 70087 70088 70089 70091 70092 70093 70094 70095 70096 79000

Customer Contact Provider Support Nate Meyer Cheryl Avery CSC Call Center Recipient Services Provider Services Steve Smith Debbie Paiz Finance Department John Padilla Customer Service Customer Service Gail Briese-Zimmer Kyra Westlake Customer Services Carl Ishmael Customer Service Norman Curtis Carl Ishmael Jayme Pu'u Provider/Beneficiary Hotline Carl Ishmael Carl Ishmael Carl Ishmael Reeshemah Trower Reeshemah Trower Reeshemah Trower Reeshemah Trower Carl Ishmael Carl Ishmael Reeshemah Trower Carl Ishmael Kijuana Wright Reeshemah Trower Holly Saelens Kristen Brown Nicole Slee Alexis Johnson Anjenette Fenske Customer Service Customer Service

Contact Number (800) 237-0757 (402) 471-9123 (404) 657-3810 (800) 343-9000 (919) 855-4045 (800) 688-6696 (800) 523-2863 (307) 777-5378 (202) 698-2000 (505) 827-1340 (800) 925-9126 (800) 541-5555 opt 14 then 11 (406) 442-6093 (602) 417-4152 (808) 952-5570 or (800) 235-4378 (502) 564-5472 (800) 562-3022 (207) 629-4318 (502) 564-5472 (808) 675-7341 (800) 292-2550 (502) 564-5472 (502) 564-5472 (502) 564-5472 (609) 631-6663 (609) 631-6663 (609) 631-6663 (609) 631-6663 (502) 564-5472 (502) 564-5472 (609) 631-6663 (502) 564-5472 (602) 417-4353 (609) 631-6663 (855) 665-4623 (855) 364-0974 (855) 364-0974 (866) 246-4356 (877) 542-9236 (855) 322-4075 (800) 562-3022

List of Automatic Crossover Trading Partner (Insurers) In Production Do Not Include Number Shown Below on Incoming Claims

Coordination of Benefits Agreement National Crossover Process Supplemental Payers and Insurers (Trading Partners) State Medicaid Agencies Trading Partner WISCONSIN MEDICAID QUALITY PROJ WISCONSIN MEDICAID QUALITY PROJ OREGON HEALTH MCD QUALITY PROJ IOWA MEDICAID QUALITY PROJ CDHCPF MCD QUALITY PROJECT ILLINOIS DEPT. OF HFS MQP NYS DEPT. OF HEALTH MQP

Updated: 03/31/2016

Identification Number(s) 79002 79003 79004 79005 79009 79010 79012

Customer Contact Katie Ploeser Katie Ploeser Chris Coon Provider Services Sandra Salus Paul Stieber Care Center

Contact Number (608) 221-4746 (608) 221-4746 (503) 945-6915 (800) 338-7909 (303) 866-5346 (312) 814-6817 (518) 649-4335