New Claims 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*:
Trading Partner Type*:
Professional Provider
Clearinghouse-Professional
Institutional Provider (Facility)
Clearinghouse-Institutional
Billing Service - Professional
Software Vendor/Developer
Billing Service - Institutional
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
HIPAA Version*
Please select which version this application is to be completed for.
HIPAA Version 5010
Professional Transactions
Claims (837)
ERA (835)
Inquiry (270, 276, 278)
Service Review(275)
Highmark Delaware (00570, 00070)
Note: The 270, 276 and 278 transactions are only available via real-time
Institutional Transactions
Claims (837)
ERA (835)
Inquiry (270, 276, 278)
Service Review(275)
Highmark Delaware (00070)
Note: The 270, 276 and 278 transactions are only available via real-time
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 instructions.
Acceptance and Submission
To continue the EDI enrollment process you must agree to the terms and conditions of Highmark's EDI services. If you already have a business relationship with Highmark, a new Agreement is not required.
New Highmark Trading Partner
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)
. Based upon your Trading Partner Type, you will be directed to the appropriate EDI Trading Partner Agreement(s) for your review.
Existing Highmark Trading Partner
If you already have a business relationship with Highmark, a new Agreement is not required. Please click the box below and enter your existing Highmark Trading Partner number so we may validate your relationship with Highmark.
Existing Relationship with Highmark
Current Highmark Trading Partner Number:
