New Trading Partner Application
Requester Information
Your Name*:
Your Title*:
Your Company*:
Your Telephone Number*:
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-
Extension:
Your Email Address*:
Trading Partner Information
Trading Partner Name*:
Street Address1*:
Street Address2:
City*:
State*:
Choose one
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip*:
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Contact Name*:
Telephone Number*:
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Extension:
Office Fax Number:
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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)
Service Review(275)
Highmark BlueCross BlueShield West Virginia (54828)
Highmark Senior Solutions Company (15459)
Institutional Transactions
Claims (837)
ERA (835)
Inquiry(270, 276, 278)
Service Review(275)
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.
NPI
Provider Name
ERA?
Yes
No
Software Vendor Information
Name of Software*:
Vendor Name*:
Contact Name*:
Contact Telephone Number*:
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-
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.
