Provider Changes
This Trading Partner Business Center web form provides capabilities for the following Payers:
Highmark BlueCross BlueShield West Virginia
(54828),
Highmark Senior Solutions Company
(15459), and
West Virginia Family Health - Medicaid
(45276)
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.
Request Type*
Please select what type of request this application is to be completed for.
Add Provider
Delete Provider
Requester Information
Your Name*:
Your Title*:
Your Company*:
Your Telephone Number*:
-
-
Extension:
Your Email Address*:
Trading Partner Information
Trading Partner Number*:
Trading Partner Name*:
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
Additional Comments
Please use this space for additional description or instruction.
