ERA Enrollment Form

ERA Enrollment Form

This Trading Partner Business Center web form provides capabilities for Highmark Delaware (00570 & 00070) and Highmark Delaware Health Options - Medicaid (47181).

Changes made on this form will update your trading partner information used for conducting business with only the Payer which is linked to the Trading Partner ID you submit on this form. You may have multiple Trading Partner IDs for use with Highmark and the payers it serves but this form applies only to the Trading Partner ID that you enter below.

Please Note: Due to data privacy requirements, ERA recipient adds/changes must be confirmed with the provider office prior to setup. Failure to provide contact information may result in a delay or denial of your request.

Provider Information

Provider Name*:
Street Address1*:
Street Address2:
City*:
State*:	Zip Code*:	-

Provider Indentifiers Information

Provider Identifiers

Provider Federal Tax Indentification (TIN) or Employer Identification Number (EIN)*:

National Provider Indentifier (NPI)*:

Other Identifiers

Trading Partner ID*:

Provider Contact Information

Provider Contact Name*:
Telephone Number*:	--
Extension:
Email Address*:

Preference for Aggregation of Remittance Data (e.g. Account Number Linkage to Provider Indentifier)

	National Provider Identification Number (NPI)
	Provider Tax Identification Number (TIN)

Reason For Submission

	New Enrollment
	Change Enrollment
	Cancel Enrollment

Authorized Signature

Printed Name of Person Submitting Enrollment
I certify that I am authorized to make this request

Fields marked with an asterisk (*) are required.