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New Trading Partner Application
Requester Information

Your Name*:
Your Title*:
Your Company*:
Your Telephone Number*: -- Extension:
Your Email Address*:
Trading Partner Information

Trading Partner Name*:
Street Address1*:
Street Address2:
City*:
State*: Zip*: -
Contact Name*:
Telephone Number*: --
Extension:
Office Fax Number: --
Internet E-mail Address:
Tax ID/Social Security Number*:
Trading Partner Type*:

Professional Provider Clearinghouse-Professional
Institutional Provider (Facility) Clearinghouse-Institutional
Billing Service - Professional Software Vendor/Developer
Billing Service - Institutional
Professional Transactions

Claims (837) ERA (835) Inquiry(270, 276, 278)
Highmark BlueCross BlueShield West Virginia (54828)
Highmark Senior Solutions Company (15459)
Institutional Transactions

Claims (837) ERA (835) Inquiry(270, 276, 278)
Highmark BlueCross BlueShield West Virginia (54828)
Highmark Senior Solutions Company (15459)
Transmission Mode*

Internet/FTP
Internet Inquiry Transactions

Since you have selected both the Internet/FTP option along with a Highmark Inquiry Transaction(270, 276, 278), you are eligible to request Real-Time inquiry service. If your practice management software supports Highmark Real-Time transactions you may select one of the real-time options listed below.

Batch Transactions Only
Both Batch Transactions and Real-Time Transactions

If you are unsure of your software's Real-Time capabilities, please contact your software vendor.
Provider Information*

Please be advised that updating era for this NPI number will result in a change for all associated providers regardless of where they are currently receiving remittance.

Please fill in the appropriate provider related fields and click the 'Add Provider' button to record the provider.

NPIProvider NameERA?
YesNo

Software Vendor Information

Name of Software*:
Vendor Name*:
Contact Name*:
Contact Telephone Number*: --
Contact Email Address:
Please check this box if you do your own EDI Software programming. 
Additional Comments

Please use this space for additional description or instruction.
Acceptance and Submission

To continue the EDI enrollment process you must agree to the terms and conditions of Highmark's EDI services. Based upon your Trading Partner Type, you will be directed to the appropriate EDI Trading Partner Agreement(s) for your review.

By clicking on this checkbox and using these services, you accept, without limitation or qualification, the terms and conditions of Highmark's EDI Trading Partner Agreement(s), in accordance with your Trading Partner Type, and acknowledge that any other EDI agreement between you and Highmark is superseded.