New DataStream Trading Partner Application

The Highmark Gateway, managed and maintained by Highmark, provides EDI capabilities for the payers listed below:

Independence Blue Cross (54704), including products issued by Keystone Health Plan East (95056), or administered by Independence Administrators (TA720); see www.ibx.com/edi for greater detail.
AmeriHealth−affiliated companies, including products issued by AmeriHealth HMO (95044), AmeriHealth Insurance Company of New Jersey including AmeriHealth PPO and Comprehensive Major Medical (60061), QCC Insurance Company d/b/a AmeriHealth Insurance Company including AmeriHealth DE − PPO (93688), or products administered by AmeriHealth Administrators (54763); see www.amerihealth.com/edi for greater detail.

Changes made on this form will update your trading partner information used for conducting business with only the payers listed above via the Highmark Gateway. You may have multiple Trading Partner IDs for use with Highmark and the payers it serves but this form applies only to the DataStream Trading Partner ID used for the payers listed above.

A new trading partner may only be requested by the Trading Partner Administrator.

Administrator Information

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

In order to confirm your identity for security purposes, please choose one of the following security questions and provide your corresponding security answer. As the Trading Partner Administrator, you will need to provide your security answer each time you request changes or information on behalf of this trading partner.

Security Question*:

Your Security Answer*:

*Security Answer:**
*Confirm Answer:**

As the Trading Partner Administrator you may also identify one or more Trading Partner Delegates that can act on your behalf to request basic changes or information for this trading partner.

Delegate Information

First Delegate Name:
First Delegate Title/Function:
First Delegate Telephone Number:	--
First Delegate Email Address:

Second Delegate Name:
Second Delegate Title/Function:
Second Delegate Telephone Number:	--
Second Delegate Email Address:

Trading Partner Information

*Trading Partner Name:**
*Street Address 1:**
Street Address 2:
*City:**
*State:**		*Zip:**	-
*Telephone Number:**	--
Extension:
Office Fax Number:	--
*Email 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.

Org NPI	Provider Name	ERA?
		YesNo

Professional Transactions

	Claims (837)	ERA (835)
Independence Blue Cross/Keystone Health Plan East
AmeriHealth (incl. AmeriHealth Administrators, AmeriHealth Insurance Company of New Jersey, AmeriHealth HMO, Inc. [Pennsylvania], AmeriHealth HMO, Inc. [Delaware])

Institutional Transactions

	Claims (837)	ERA (835)
Independence Blue Cross/Keystone Health Plan East
AmeriHealth (incl. AmeriHealth Administrators, AmeriHealth Insurance Company of New Jersey, AmeriHealth HMO, Inc. [Pennsylvania], AmeriHealth HMO, Inc. [Delaware])

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.

Acceptance and Submission

To activate your new DataStream Trading Partner ID, you must agree to the terms and conditions of the appropriate Trading Partner Agreement.
By clicking on this checkbox and using these services, you accept, without limitation or qualification, the terms and conditions of the Trading Partner Agreement. (Based upon your Trading Partner Type, this link will open the appropriate Trading Partner Agreement for your review.)

Please verify the information you have entered before continuing to submission page.

Fields marked with an asterisk (*) are required.