Update Claims Transactions

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.

Requester Information

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

Trading Partner Information

Trading Partner Number*:
Trading Partner Name*:

Trading Partner Type*:

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

HIPAA Version*

Please select which version this application is to be completed for.
HIPAA Version 5010

Professional Transactions

	Claims (837, 275CA)	ERA (835)	Inquiry (270/271, 276/277)	Prior Authorization (278, 275SR)
Highmark Delaware (00570, 00070)

Note: The 270, 276 and 278 transactions are only available via real-time

Institutional Transactions

	Claims (837, 275CA)	ERA (835)	Inquiry (270/271, 276/277)	Prior Authorization (278, 275SR)
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*:	--
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.