Blue Medicare Advantage HMO Contracted Providers

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Appendix DBlue Medicare Advantage HMOContracted ProvidersAmbulatory Surgicenters .2Durable Medical Equipment .3Home Health Care .4Home Infusion .6Hospice 7Inpatient – Metro Hospitals .8Long Term Acute Care .12Mental Health IP/OP .13Orthotic & Prosthetic .14Hospital Based Outpatient Surgery .17Renal Dialysis .20Skilled Nursing Facilities 27Substance Use Disorder 32A Division of Healthcare Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association2

Appendix DMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider Type Effective Date Cancel DateProvider NameAddressCityStateZipTelephoneChangeCodeChange DateSurgicenter01/01/2013Center for Reconstructive Surgery6309 W 95th StOak LawnIL60453 (708) 499-3355Surgicenter01/01/2013DMG Pain Management Surgery Ct2940 Rolling Ridge Rd.NapervilleIL60564 (630) 303-5304 ASurgicenter01/01/2013DMG Surgical Center, LLC2725 S. Technology center01/01/2013Elmhurst Outpatient Surgery1200 S. York RoadNovamed Surgery Ct of Chicago Northshore3034 W. Peterson Ave.LLG60148 (630) 942-7998601265626 (630) 758-8457ChicagoIL60659 (773) 973-7432 A11/26/12Surgicenter01/01/2013Novamed Surgery Ct of Oak Lawn d/b/a/Center for Reconstructive Surgery6311 W. 95th St.Oak LawnIL60453 (708) 499-3355 A11/26/12Surgicenter01/01/2013Novamed Surgery Ct of River Forest7427 Lake St.River ForestIL60305 (708) 771-3334 A11/26/12Surgicenter01/01/2013IL60008 (847) /01/2013675 West Kirchoff Road2940 Rolling Ridge Road, Suite2003115 N. Harlem Avenue2725 Technology Drive120 N. LaGrange Road1875 W. Dempster StreetArlington rgicenterNW Community Day SurgeryPain Management Surgical Center ofDuPage Medical GroupResurrection Health Care Surgery CenterSurgical Center of DuPage Medical GroupUnited Shockwave Therapies - WestUnited Shockwave k RidgeILILIlILIL6056460634601486052560068(630) 697-6000 A(773) 889-2000(630) 348-3300 A(708) 352-6666 A(847) 696-221011/26/1211/01/1211/01/1211/06/12A: NewC: CancelN: Prov. NameP: Prov. NumberR: ReinstateAC: Accreditation CancelAD: AddressCP: Cancel prov # changedPN: Name and NumberTE: TelephoneNumberTI: Transfer intoa classTO: Transfer outof a classRev. 7-20143A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider Type Effective Date Cancel DateProvider /2013Apria Health Care4055 Steele Dr.Machesney PkIL61115 (847) 252-2000DME01/01/2013Apria Health Care1015 W. Deitweiller DrivePeoriaIL61615 (309) 691-1012DME01/01/2013Apria Health Care1581 E. 90th PlaceMerrillvilleIN46410 (219) 736-1302DME01/01/2013Apria Health Care775 E. Linton Ave.SpringfieldILDMEDME01/01/201301/01/20133010 Woodcreek Dr300 Randall RoadDowners GroveGenevaILILDME01/01/2013Byram HealthCareDelnor Comm. Hosp. Home HlthDupage Medical Group dba PremierMedical Equipment62703 (217) 789-0461605155415 (800) 681-13954200 (630) 513-0370428 Pennsylvania AveGlen EllynIL60137 (630) 545-7770DME01/01/2013ElginIL60124 (800) 307-5930DME01/01/2013Edgepark Medical Supplies1360 Madeline LaneElmhurst Memorial Home Health DME dba855 N. Church CenterAction Medical EquipmentElmhurstIL60126 (630) 758-7000DMEDME01/01/201301/01/2013Resurrection ServicesUnited Seating and MobilityMorton GroveLombardILIL60053 (847) 568-850060148A5747 W. Dempster335 Eisenhower Lane SoChange Date11/02/12A: NewC: CancelN: Prov. NameP: Prov. NumberR: ReinstateAC: Accreditation CancelAD: AddressCP: Cancel prov # changedPN: Name and NumberTE: TelephoneNumberTI: Transfer intoa classTO: Transfer outof a classRev. 7-20144A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider Type Effective Date Cancel DateProvider NameAddressCityStateZipTelephoneChangeCodeHome Health01/01/2013Advocate Home Health Care2311 W. 22nd StreetOak BrookIL60523 (630) 572-1232Home Health01/01/2013Alexian Brothers Home Health1515 E. Lake StreetHanover ParkILHome Health02/01/2014CNS HOME HEALTH & HOSPICECAROL STREAMILHome Health02/01/2014COMMUNITY ALLIANCE HOME HEALTH690 E NORTH AVE STE 100ONE MERCHANTS PLAZA STE202OSWEGOILHome Health01/01/2013Delnor Community Hosp. HHA300 Randall RoadGenevaIL60133601882172605439453601344200Home Health01/01/2013Elmhurst Memorial HomeHealth855 N. Church CourtElmhurstIL60126 (630) 530-1201Home Health01/01/2013Oak LawnIL60453 (708) 422-2934Home Health01/01/2013Interim HealthCare10735 S Cicero, Suite 100Mt. Sinai Hospital & Med. Ctr. Home Health03/01/2013 Care15th at CaliforniaChicagoILHome Health01/01/201301/01/2013 New Beginnings Home Health Care13011 S 104th St, Suite 205Palos ParkIL60605 (773) 542-2000604641512 (708) 671-1700 CHome Health01/01/2013Northwest Comm. Hosp. Home Care3060 Salt Creek LaneArlington HgtsIL60005 (847) 618-1000Home Health01/01/2013Palos Community Hosp. Home Health15295 E. 127th StreetLemontIL60439 (630) 257-1111Home Health01/01/2013Private Home Care Unlimited5517 N. CumberlandChicagoILHome Health01/01/2013Provena Home Health Joliet1060 Essington RoadJolietILHome Health01/01/2013Provena Home Health Kankakee179 E. BethelBourbonnaisILHome Health01/01/20131501 Interstate me Health01/01/2013Provena Home Health Waukegan222 S. Greenleaf Ave.WaukeganIL60031 (847) 360-7660Home Health01/01/2013Provena St. Joseph (Elgin)799 South McLean Blvd.ElginIL60123 (847) 622-2055Home Health01/01/2013Residentail Home Health Illinois40 Shuman Blvd, Suite 204NapervilleILHome Health01/01/2013Resurrection Home Health Services2380 E Dempster StDes PlainesIL60563 (630) 527-6830600164839 (847) 493-480011/30/2013 Provena Home Health UrbanaChange Date(847) 437-550063066570006308980122(630) 513-037001/01/2013(773) 467-6000(815) 741-7371(815) 937-2475(217) 355-4120Rev. 7-20145A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider Type Effective Date Cancel DateProvider NameAddressHome Health01/01/201301/01/2013 RMC Home Health Care1905 W. Court StreetKankakeeILZipTelephone609013163 (815) 935-3272Home Health01/01/201312/09/2013 Sherman Home Care Partners1019 E. Chicago StreetElginIL60120 (847) 429-6200Home Health01/01/2013Sherman Home Care Partners901 Center Street, Suite 2001AElginIL60120 (224) 783-6200Home Health01/01/2013Silver Cross Home Health1200 Maple RoadJolietIL60432 (815) 740-7124Home Health01/01/2013Swedish Covenant Hospital HH2965 W. Peterson Ave.ChicagoIL60659 (773) 275-9700A: NewC: CancelN: Prov. NameP: Prov. NumberR: ReinstateAC: Accreditation CancelAD: AddressCP: Cancel prov # changedPN: Name and NumberTE: TelephoneNumberTI: Transfer intoa classTO: Transfer outof a class6CityStateChangeCodeChange Date

Appendix DMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider Type Effective Date Cancel DateProvider NameAddressCityStateZipTelephoneHome HIT01/01/2013Advocate Home Care Products1441 Branding Lane, Suite 310Downers GroveIL60515 (630) 963-3200Home HIT01/01/2013Alexian Brothers Home Health1515 Lake StreetHanover ParkIL60133 (847) 956-5464Home HIT01/01/2013Coram Health Care Corp. of IN1290 Arrowhead Ct.Crown PointIN46307 (219) 661-0272Home HIT01/01/2013Coram HealthCare Corp of IL1471 E. Business Center Dr.Mt. ProspectIL60056 (847) 294-6422Home HIT01/01/2013Elmhurst Mem Hosp Home Infusion200 Berteau AvenueElmhurstIL60126 (630) 993-5165Home HIT01/01/2013Loyola Univ Med Ctr Home Care2160 S. First AvenueMaywoodIL60153 (708) 216-4983Home HIT01/01/2013MacNeal Infusion TherapyBerwynIL60402 (708) 447-3555Home HIT01/01/2013Pri Med Infusion Services3249 S. Oak Park Ave.5517 N Cumberland Ave, Suite915ChicagoIL60656 (773) 467-6000Home HIT01/01/2013Sherman Home Care Partners901 Center Street, Suite 2001AElginIL60120 (224) 783-6200ChangeCodeChange DateA: NewC: CancelN: Prov. NameP: Prov. NumberR: ReinstateAC: Accreditation CancelAD: AddressCP: Cancel prov # changedPN: Name and NumberTE: TelephoneNumberTI: Transfer intoa classTO: Transfer outof a classRev. 7-20147A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider Type Effective Date Cancel DateHospice01/01/2013Provider NamePRESENCE HOSPICE ELGINAddress799 S MCLEAN BLVD STE 101CityELGINStateILZipTelephone601236702 8479315553ChangeCodeChange DateA: NewC: CancelN: Prov. NameP: Prov. NumberR: ReinstateAC: Accreditation CancelAD: AddressCP: Cancel prov # changedPN: Name and NumberTE: TelephoneNumberTI: Transfer intoa classTO: Transfer outof a classRev. 7-20148A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DProvider TypeInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKEffective Date Cancel DateProvider NameAddressCityState01/01/2014ADVENTIST BOLINGBROOK HOSPITAL500 REMINGTON BLVDBOLINGBROOKIL01/01/2014ADVENTIST GLEN OAKS HOSPITAL701 WINTHROP AVEGLENDALE HEIGHTS IL01/01/2014ADVENTIST HINSDALE HOSPITAL120 N OAK STHINSDALEIL01/01/2014ADVENTIST LAGRANGE MEMORIAL HOSP5101 S WILLOW SPRINGS RDLA GRANGEIL01/01/2013Advocate Condell Medical Center801 S. Milwaukee AvenueLibertyvilleIL01/01/2013Advocate Illinois Masonic Medical Center836 Wellington Ave.ChicagoIL01/01/2013Alexian Brothers Behavioral Health Hospital 1650 Moonlake Blvd.Hoffman EstatesIL01/01/2013Alexian Brothers Medical Center800 West Biesterfield RoadElk Grove VillageIL01/01/2013Central DuPage Hospital25 North Winfield RoadWinfieldIL01/01/2013Christ Hosp. & Med. Ctr. - Advocate4440 West 95th StreetOak LawnIL01/01/2013Delnor Community Hospital300 Randall RoadGenevaIL01/01/2013Edward Hospital801 South Washington StreetNapervilleIL01/01/2013Elmhurst Memorial Hospital155 East Brush Hill RdElmhurstIL01/01/2014GLENBROOK HOSPITAL2100 PFINGSTEN RDGLENVIEWIL01/01/2013Good Samaritan Hospital - Advocate3815 Highland AvenueDowners GroveIL01/01/2013Good Shepherd Hospital - Advocate450 West Highway 22BarringtonIL01/01/2014HIGHLAND PARK HOSPITAL777 PARK AVE WESTHIGHLAND PARKIL01/01/2014HOLY CROSS HOSPITAL2701 W 68TH STCHICAGOIL01/01/2013Linden Oaks Hospital852 West neChangeCodeChange Date6303125000630545800063085690007083521200(847) 362-2900(773) 975-1600(847) 882-1600(847) 00261301605151500(630) 682-160060010600352433606291813605406400(847) 381-9600(708) 684-8000(630) 208-3000(630) 355-0450(630) 833-14008476575800(630) 275-590084743280007738849000(630) 305-5500Rev. 7-20149A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DProvider TypeInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKEffective Date Cancel DateProvider 1/01/2013Louis A. Weiss Memorial Hospital4646 North Marine DriveChicagoIL01/01/2013Loyola University Med. Ctr.2160 South First Ave.MaywoodIL01/01/2013Lutheran General Hospital1775 Dempster StreetPark RidgeIL01/01/2013MacNeal Memorial Hospital3249 S. Oak Park Ave.BerwynIL05/01/2013MARIANJOY REHABILITATION HOSPITAL26 W 171 ROOSEVELT RDWHEATONIL01/01/2013Mount Sinai Hospital Medical CenterCalifornia Avenue at 15th St.ChicagoIL01/01/2014NORTHSHORE UNIVERSITY HEALTHSYSTE2650 RIDGE AVEEVANSTONIL01/01/2013Northwest Community Health Care800 W. Central Rd.Arlington HgtsIL01/01/2013Our Lady of the Resurrection Med. Ct.5645 W. Addison StreetChicagoIL01/01/2013Palos Community Hospital12251 South 80th Ave.Palos HeightsIL01/01/2013Presence Resurrection Medical Center7435 West Talcott St.ChicagoIL01/01/2013Provena Mercy Medical Center1325 North Highland Ave.AuroraIL01/01/2013Provena St. Joseph Hospital77 North Airlite StreetElginIL01/01/2013Provena St. Joseph Med. Center333 North Madison St.JolietIL01/01/2013Provena St. Mary's Hospital500 W. Court S.KankakeeIL06/01/2013RML CHICAGO3435 W VAN BURENCHICAGOIL06/01/2013RML SPECIALTY HOSPITAL5601 S COUNTY LINE RDHINSDALEIL01/01/2013Rush Copley Memorial Hosp.2000 Ogden 22201/01/2013Saint Joseph Hospital2900 North Lake Shore Dr.ChicagoIL60657 (773) 665-3000ChangeCodeChange Date(773) 878-8700(708) 216-9000(847) 723-2210(708) 783-91006309098000(773) 542-20008475705020(847) 618-1000(773) 282-7000(708) 923-4000(773) 774-8000(630) 859-2222(847) 695-3200(815) 725-7133(815) 937-249063028640006302864223(630) 978-6200Rev. 7-201410A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DProvider TypeInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroInpatient MetroMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKEffective Date Cancel DateProvider NameAddressCityState01/01/2013Schwab Rehabilitation Hospital1401 S. California Ave.ChicagoIL01/01/2013Sherman Hospital1425 N Randall RoadElginIL01/01/2013Silver Cross Hospital1900 Silver Cross BlvdNew LenoxIL01/01/2014SKOKIE HOSPITAL9600 GROSS POINT RDSKOKIEIL01/01/2013South Suburban Hospital - Advocate17800 S. Kedzie Ave.Hazel CrestIL01/01/2013St. Alexius Med. Center1555 N. Barrington Rd.Hoffman EstatesIL01/01/2013St. Bernard Hospital326 West 64th StreetChicagoIL01/01/2013St. Elizabeth Hospital (Chicago)1431 N. Claremont Ave.ChicagoIL01/01/2013St. Francis Hospital (Evanston)355 Ridge AvenueEvanstonIL01/01/2013St. Mary and Elizabeth Medical Center2233 W. Division StreetChicagoIL01/01/2013Swedish Covenant Hospital5145 N. California Ave.ChicagoIL01/01/2013Trinity Hospital - Advocate2320 East 93rd StreetChicagoIL01/01/2013University of Chgo. Med. Center5841 Maryland Ave.ChicagoIL01/01/2013West Suburban Hospital3 Erie CourtOak ParkIL01/01/2013Westlake Community Hospital1225 West Lake StreetMelrose oneChangeCodeChange Date(773) 522-2010(847) 742-9800(815) 300-11008476779600(708) 799-8000(847) 843-2000(773) 962-3900(773) 278-2000(847) 316-4000(312) 770-2000(773) 878-8200(773) 978-2000(773) 702-1000(708) 383-6200(708) 671-3000A: NewC: CancelN: Prov. NameP: Prov. NumberR: ReinstateAC: Accreditation CancelAD: AddressCP: Cancel prov # changedRev. 7-201411A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DProvider Type Effective Date Cancel DateMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider NameAddressCityStateZipTelephoneChangeCodeChange DatePN: Name and NumberTE: TelephoneNumberTI: Transfer intoa classTO: Transfer outof a classRev. 7-201412A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider Type Effective Date Cancel DateProvider NameLong Term01/01/2013Holy Family Medical CenterAcute CareAddress100 North River RoadCityDes PlainesStateILZipTelephoneChangeCodeChange Date60016 (847) 297-1800A: NewC: CancelN: Prov. NameP: Prov. NumberR: ReinstateAC: Accreditation CancelAD: AddressCP: Cancel prov # changedPN: Name and NumberTE: TelephoneNumberTI: Transfer intoa classTO: Transfer outof a classRev. 7-201413A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider Type Effective Date Cancel DateMental Health01/01/2013Mental Health01/01/2013Mental Health01/01/2013Mental Health01/01/2013Mental Health01/01/2013Mental Health01/01/2013Mental Health01/01/2013Mental Health01/01/2013Mental Health01/01/2013Mental Health01/01/2013Mental Health01/01/2013Provider NameHoly Family Medical Center/ Key's toRecoveryResurrection Behavioral Health - RespiteResurrection Behavioral Health at HolyFamily Med CtResurrection Behavioral Health at Our Ladyof the Resurrection Med CtResurrection Behavioral Health at Pillares(Berwyn)Resurrection Behavioral Health at ProCare(Broadview)Resurrection Behavioral Health at ProCare(Melrose Pk)Resurrection Behavioral Health at ProCare(Westchester)Resurrection Behavioral Health at ProCare(Westchester)Resurrection Behavioral Health atResurrection Med CtResurrection Behavioral Health at SaintFrancis ge Date100 N River Rd.Des PlainesIL60016 (847) 298-9355 A11/26/12117 S 6th Ave.MaywoodIL60153 (708) 410-0615 A11/26/12100 North River Road.Des PlainesIL60016 (708) 410-0615 A11/26/125645 W. Addison St.ChicagoIL60634 (708) 410-0615 A11/26/126918 Windsor Avenue, Suite 410 BerwynIL60402 (708) 410-0615 A11/26/121820 S 25th AveBroadviewIL60155 (708) 410-0615 A11/26/121414 Main St.Melrose ParkIL60160 (708) 410-0615 A11/26/129855 Roosevelt RdWestchesterIL60154 (708) 410-0615 A11/26/129845 Roosevelt RdWestchesterIL60154 (708) 410-0615 A11/26/127435 W. Talcott Ave.ChicagoIL60631 (708) 410-0615 A11/26/12355 Ridge AveEvanstonIL60202 (708) 410-0615 A11/26/12Mental Hlth - IP 01/01/2013Saint Joseph Behavioral Health2900 N Lake Shore DrChicagoIL60657 (773) 665-3000 A11/26/12Mental Hlth - IP 01/01/2013Saints Mary and Elizabeth Medical Center2233 W Division StChicagoIL60622 (312) 770-2000 A11/26/12Mental Hlth - OP 01/01/2013Saint Joseph Behavioral Health2913 N Commonwealth Dr.ChicagoIL60657 (773) 665-3000 A11/26/12Mental Hlth - OP 01/01/2013Saints Mary and Elizabeth Medical Center1431 N. ClaremontChicagoIL60622 (312) 633-5890 A11/26/12Mental Hlth - OP 01/01/2013Saints Mary and Elizabeth Medical Center1127 N OakleyChicagoIL60622 (312) 770-2317 A11/26/12A: NewC: CancelN: Prov. NameP: Prov. NumberR: ReinstateRev. 7-201414A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Appendix DProvider Type Effective Date Cancel DateMEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORKProvider NameAddressCityStateZipTelephoneChangeCodeChange DateAC: Accreditation CancelAD: AddressCP: Cancel prov # changedPN: Name and NumberTE: TelephoneNumberTI: Transfer i

Pain Management Surgical Center of DuPage Medical Group 2940 Rolling Ridge Road, Suite 200 Naperville IL 60564 (630) 697-6000 A; 11/01/12 Surgicenter 01/01/2013; Resurrection Health Care Surgery Center 3115 N. Harlem Avenue; Chicago IL; 60634 (773) 889-2000; Surgicenter 01/01/2013 Surgical Center of DuPage

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