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GHP ID

Type of GHP

TPA Tax ID

Name/Address of GHP

Rx BIN

Rx PCN

Rx Group

Use your assigned group number from your invoice

D

35-2145715

Cost Alliance Anthem Blue Cross and Blue Shield P. O. Box 27401 Richmond, VA 23279

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Use your assigned group number from your invoice

D

35-2145715

Key Share Anthem Blue Cross and Blue Shield P. O. Box 27401 Richmond, VA 23279

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Use your assigned group number from your invoice

D

35-2145715

Value Alliance Anthem Blue Cross and Blue Shield P. O. Box 27401 Richmond, VA 23279

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*For Key Advantage, TLC HDHP and Kaiser Permanente HMO (Beginning in 2005-06), you must complete two entries in Parts II and III, one for the medical plan (plan types D or B) and one for the prescription drug plan (plan type U).

Part III: Employee Information

  • Provide appropriate answers related to designated worker’s active employment. Be sure to provide both medical and prescription drug entries for Key Advantage, TLC HDHP and Kaiser Permanente HMO members (Beginning in 2005-06).

Part IV: Certification

  • Provide requested information

The Office of Health Benefits and The Local Choice anticipate that you will begin experiencing a reduction in the number of Data Match requests as the year progresses since we have entered into a Voluntary Data Sharing Agreement with the Centers for Medicare and Medicaid Services and will be communicating with that agency quarterly to exchange eligibility information.

If you have any questions, please contact Walter Norman, TLC Program Manager at 804/786-6460 or by e-mail at walter.norman@dhrm.virginia.gov.

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