Appendix D Blue Medicare Advantage HMO Contracted Providers Ambulatory Surgicenters ………………………………………………………... 2 Durable Medical Equipment ……………………………………………………... 3 Home Health Care ………………………………………………………………... 4 Home Infusion ……………………………………………………………………. 6 Hospice …………………………………………………………………………… 7 Inpatient – Metro Hospitals ………………………………………………………. 8 Long Term Acute Care ………………………………………………………….. 12 Mental Health IP/OP …………………………………………………………….. 13 Orthotic & Prosthetic …………………………………………………………….. 14 Hospital Based Outpatient Surgery ………………………………………………. 17 Renal Dialysis ……………………………………………………………………. 20 Skilled Nursing Facilities ………………………………………………………… 27 Substance Use Disorder ………………………………………………………… 32 A Division of Healthcare Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 2 Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Surgicenter 01/01/2013 Center for Reconstructive Surgery 6309 W 95th St Oak Lawn IL 60453 (708) 499-3355 Surgicenter 01/01/2013 DMG Pain Management Surgery Ct 2940 Rolling Ridge Rd. Naperville IL 60564 (630) 303-5304 A 11/26/12 Surgicenter 01/01/2013 DMG Surgical Center, LLC 2725 S. Technology Drive Lombard IL 60148 (630) 942-7998 60126- Surgicenter 01/01/2013 Elmhurst Outpatient Surgery 1200 S. York Road Elmhurst IL 5626 (630) 758-8457 Novamed Surgery Ct of Chicago Northshore Surgicenter 01/01/2013 LLG 3034 W. Peterson Ave. Chicago IL 60659 (773) 973-7432 A 11/26/12 Novamed Surgery Ct of Oak Lawn d/b/a/ Surgicenter 01/01/2013 Center for Reconstructive Surgery 6311 W. 95th St. Oak Lawn IL 60453 (708) 499-3355 A 11/26/12 Surgicenter 01/01/2013 Novamed Surgery Ct of River Forest 7427 Lake St. River Forest IL 60305 (708) 771-3334 A 11/26/12 Surgicenter 01/01/2013 NW Community Day Surgery 675 West Kirchoff Road Arlington Hgts IL 60008 (847) 618-1000 Pain Management Surgical Center of 2940 Rolling Ridge Road, Suite Surgicenter 01/01/2013 DuPage Medical Group 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 Medical Group 2725 Technology Drive Lombard Il 60148 (630) 348-3300 A 11/01/12 Surgicenter 01/01/2013 United Shockwave Therapies - West 120 N. LaGrange Road LaGrange IL 60525 (708) 352-6666 A 11/06/12 Surgicenter 01/01/2013 United Shockwave Therapies-North 1875 W. Dempster Street Park Ridge IL 60068 (847) 696-2210 A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class Rev. 7-2014 3 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date DME 01/01/2013 Apria Health Care 4055 Steele Dr. Machesney Pk IL 61115 (847) 252-2000 DME 01/01/2013 Apria Health Care 1015 W. Deitweiller Drive Peoria IL 61615 (309) 691-1012 DME 01/01/2013 Apria Health Care 1581 E. 90th Place Merrillville IN 46410 (219) 736-1302 DME 01/01/2013 Apria Health Care 775 E. Linton Ave. Springfield IL 62703 (217) 789-0461 60515- DME 01/01/2013 Byram HealthCare 3010 Woodcreek Dr Downers Grove IL 5415 (800) 681-1395 DME 01/01/2013 Delnor Comm. Hosp. Home Hlth 300 Randall Road Geneva IL 4200 (630) 513-0370 Dupage Medical Group dba Premier DME 01/01/2013 Medical Equipment 428 Pennsylvania Ave Glen Ellyn IL 60137 (630) 545-7770 DME 01/01/2013 Edgepark Medical Supplies 1360 Madeline Lane Elgin IL 60124 (800) 307-5930 Elmhurst Memorial Home Health DME dba DME 01/01/2013 Action Medical Equipment 855 N. Church Center Elmhurst IL 60126 (630) 758-7000 DME 01/01/2013 Resurrection Services 5747 W. Dempster Morton Grove IL 60053 (847) 568-8500 DME 01/01/2013 United Seating and Mobility 335 Eisenhower Lane So Lombard IL 60148 A 11/02/12 A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class Rev. 7-2014 4 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Home Health 01/01/2013 Advocate Home Health Care 2311 W. 22nd Street Oak Brook IL 60523 (630) 572-1232 Home Health 01/01/2013 Alexian Brothers Home Health 1515 E. Lake Street Hanover Park IL 60133 (847) 437-5500 60188 Home Health 02/01/2014 CNS HOME HEALTH & HOSPICE 690 E NORTH AVE STE 100 CAROL STREAM IL 2172 6306657000 ONE MERCHANTS PLAZA STE 60543 Home Health 02/01/2014 COMMUNITY ALLIANCE HOME HEALTH 202 OSWEGO IL 9453 6308980122 60134- Home Health 01/01/2013 Delnor Community Hosp. HHA 300 Randall Road Geneva IL 4200 (630) 513-0370 Home Health 01/01/2013 Elmhurst Memorial HomeHealth 855 N. Church Court Elmhurst IL 60126 (630) 530-1201 Home Health 01/01/2013 Interim HealthCare 10735 S Cicero, Suite 100 Oak Lawn IL 60453 (708) 422-2934 Mt. Sinai Hospital & Med. Ctr. Home Health Home Health 01/01/2013 03/01/2013 Care 15th at California Chicago IL 60605 (773) 542-2000 60464- Home Health 01/01/2013 01/01/2013 New Beginnings Home Health Care 13011 S 104th St, Suite 205 Palos Park IL 1512 (708) 671-1700 C 01/01/2013 Home Health 01/01/2013 Northwest Comm. Hosp. Home Care 3060 Salt Creek Lane Arlington Hgts IL 60005 (847) 618-1000 Home Health 01/01/2013 Palos Community Hosp. Home Health 15295 E. 127th Street Lemont IL 60439 (630) 257-1111 Home Health 01/01/2013 Private Home Care Unlimited 5517 N. Cumberland Chicago IL 60656 (773) 467-6000 60435- Home Health 01/01/2013 Provena Home Health Joliet 1060 Essington Road Joliet IL 8200 (815) 741-7371 60914- Home Health 01/01/2013 Provena Home Health Kankakee 179 E. Bethel Bourbonnais IL 1456 (815) 937-2475 61822- Home Health 01/01/2013 11/30/2013 Provena Home Health Urbana 1501 Interstate Drive Champaign IL 1006 (217) 355-4120 Home Health 01/01/2013 Provena Home Health Waukegan 222 S. Greenleaf Ave. Waukegan IL 60031 (847) 360-7660 Home Health 01/01/2013 Provena St. Joseph (Elgin) 799 South McLean Blvd. Elgin IL 60123 (847) 622-2055 Home Health 01/01/2013 Residentail Home Health Illinois 40 Shuman Blvd, Suite 204 Naperville IL 60563 (630) 527-6830 60016- Home Health 01/01/2013 Resurrection Home Health Services 2380 E Dempster St Des Plaines IL 4839 (847) 493-4800 Rev. 7-2014 5 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date 60901- Home Health 01/01/2013 01/01/2013 RMC Home Health Care 1905 W. Court Street Kankakee IL 3163 (815) 935-3272 Home Health 01/01/2013 12/09/2013 Sherman Home Care Partners 1019 E. Chicago Street Elgin IL 60120 (847) 429-6200 Home Health 01/01/2013 Sherman Home Care Partners 901 Center Street, Suite 2001A Elgin IL 60120 (224) 783-6200 Home Health 01/01/2013 Silver Cross Home Health 1200 Maple Road Joliet IL 60432 (815) 740-7124 Home Health 01/01/2013 Swedish Covenant Hospital HH 2965 W. Peterson Ave. Chicago IL 60659 (773) 275-9700 A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class 6 Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Home HIT 01/01/2013 Advocate Home Care Products 1441 Branding Lane, Suite 310 Downers Grove IL 60515 (630) 963-3200 Home HIT 01/01/2013 Alexian Brothers Home Health 1515 Lake Street Hanover Park IL 60133 (847) 956-5464 Home HIT 01/01/2013 Coram Health Care Corp. of IN 1290 Arrowhead Ct. Crown Point IN 46307 (219) 661-0272 Home HIT 01/01/2013 Coram HealthCare Corp of IL 1471 E. Business Center Dr. Mt. Prospect IL 60056 (847) 294-6422 Home HIT 01/01/2013 Elmhurst Mem Hosp Home Infusion 200 Berteau Avenue Elmhurst IL 60126 (630) 993-5165 Home HIT 01/01/2013 Loyola Univ Med Ctr Home Care 2160 S. First Avenue Maywood IL 60153 (708) 216-4983 Home HIT 01/01/2013 MacNeal Infusion Therapy 3249 S. Oak Park Ave. Berwyn IL 60402 (708) 447-3555 5517 N Cumberland Ave, Suite Home HIT 01/01/2013 Pri Med Infusion Services 915 Chicago IL 60656 (773) 467-6000 Home HIT 01/01/2013 Sherman Home Care Partners 901 Center Street, Suite 2001A Elgin IL 60120 (224) 783-6200 A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class Rev.