New Trading Partner Form

Administrator Information

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

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*

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 Address1*

Street Address2

City*

State*

Zip*

Telephone Number*

Extension

Email Address*

Tax ID*

Trading Partner Type

Professional Provider

Institutional Provider (Facility)

Clearinghouse-Professional

Clearinghouse-Institutional

Billing Service - Professional

Billing Service - Institutional

Software Vendor/Developer

Transactions*

	Claims (837, 275CA)	ERA (835)
Highmark Western and Northeastern New York Inc. (55204)

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.

Group NPI#*

Provider Name*

ERA*

Yes

Validation Result Message

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 instruction

Acceptance and Submission

To continue the EDI enrollment process you must agree to the terms and conditions of Highmark's EDI services. Based upon your Trading Partner Type, you will be directed to the appropriate EDI Trading Partner Agreement(s) for your review.

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), in accordance with your Trading Partner Type, and acknowledge that any other EDI agreement between you and Highmark is superseded.