5010 EDI Transaction Application to Create New Trading Partner
Requester Information
Your Name*:
Your Title*:
Your Company*:
Your Telephone Number*: -- Extension:
Your Email Address*:
Trading Partner Information
Trading Partner Name*:
Street Address1*:
Street Address2:
City*:
State*: Zip*: -
Contact Name*:
Telephone Number*: --
Extension:
Office Fax Number: --
Internet E-mail Address:
Tax ID/Social Security Number*:
Administrator Information

The Administrator will act as the primary contact for this Trading Partner. All responses will be sent via email to the Administrator as well as the requester listed at the top of this application. Please complete section with the information necessary to identify the primary contact, or Administrator, for this Trading Partner.

Administrator Name*:
Telephone Number*: --
Extension:
E-mail Address*:
Trading Partner Type*:
Professional Provider Clearinghouse-Professional
Institutional Provider (Facility) Clearinghouse-Institutional
Billing Service - Professional Software Vendor/Developer
Billing Service - Institutional
Professional Transactions
Claims (837) ERA (835) Inquiry(270, 276, 278) Service Review(275)
Highmark (54771)
Highmark Senior Health Company (15460)
Institutional Transactions
Claims (837) ERA (835) Inquiry(270, 276, 278) Service Review(275)
Highmark Central Region (54771C)
Highmark Southeastern Region (54771S)
Highmark Western Region (54771W)
Highmark Senior Health Company (15460)
Transmission Mode*
Internet/FTP
Internet Transactions
If your practice management software supports Highmark Real-Time transactions (837,270,276,278) you may select the real-time option listed below.
The 270, 276 and 278 transactions are only available via real-time.

Batch Transactions Only
Both Batch Transactions and Real-Time Transactions

If you are unsure of your software's Real-Time capabilities, please contact your software vendor.
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.

NPIProvider NameERA?
YesNo

Software Vendor Information*
Name of Software*:
Vendor Name*:
Contact Name*:
Contact Telephone Number*: -- Extension:
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.