EDI Application to Update Transactions
Requester Information
Your Name*:
Your Title*:
Your Company*:
Your Telephone Number*: -- Extension:
Your Email Address*:
Trading Partner Information
Trading Partner Number*:
Trading Partner Name*:
Administrator Information

The Administrator will act as the primary contact for this Trading Partner. All responses will be sent via email to the Administrator as well as the requester listed at the top of this application. Please complete section with the information necessary to identify the primary contact, or Administrator, for this Trading Partner.

Administrator Name*:
Telephone Number*: --
Extension:
E-mail Address*:
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 (54771)
Highmark Senior Health Company (15460)
Institutional Transactions
Claims (837) ERA (835) Inquiry(270, 276, 278)
Highmark Central Region (54771C)
Highmark Southeastern Region (54771S)
Highmark Western Region (54771W)
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.
Software Vendor Information
Name of Software*:
Vendor Name*:
Please check this box if you do your own EDI Software programming. 
Additional Comments
Please use this space for additional description or instruction.