Resources

This section contains important billing and claims submission guidelines and other reference information to help you successfully conduct standard electronic transactions with Highmark.

Information about system maintenance and Electronic Data Interchange (EDI) changes can be found on our News page.

Resources and Reference Documents

v5010 Provider Companion Guide - opens in a new tab

This document addresses how trading partners conduct professional claim, institutional claim, claim acknowledgment, , claim payment advice and real-time inquiries through HIPAA standard electronic transactions  with Highmark in the 5010 version. This document supplements the HIPAA-mandated v5010 ASC X12 Implementation Guides and addenda with clarifications and payer-specific usage and content requirements.

Real-Time Inquiry Connectivity Specifications - opens in a new tab

Addresses the technical requirements for conducting inquiry transactions with Highmark in real-time mode.

Real-Time Claim Adjudication and Estimation Connectivity Specifications - opens in a new tab

Addresses the technical requirements for conducting claim adjudication and claim estimation transactions with Highmark in real-time mode.

Trading Partner Agreement: Providers - opens in a new tab

Trading partners who are professional or institutional providers will need to execute a Trading Partner Agreement with Highmark  to conduct EDI business with  Highmark.

Trading Partner Agreement: Clearinghouses and Vendors - opens in a new tab

Trading partners who are clearinghouses, billing services, or software vendors will need to execute a Trading Partner Agreement with Highmark  to conduct EDI business with  Highmark.

Secure Transport SFTP Specifications - opens in a new tab

This document addresses the Internet file transfer options available for Secure Transport, Highmark's secure file transfer protocol (SFTP) server. Trading partners must meet these technical requirements in order to connect to the Highmark Gateway.

v5010 ASC X12 Implementation Guides

This section provides a link to where trading partners may acquire the HIPAA-mandated v5010 ASC X12 Implementation Guides and their related standardized code lists.

PWK Fax Cover Sheet

This Supplemental Claim Information Cover Sheet is used when faxing or mailing supplemental information in support of an electronic claim. See the PWK instructions in the Attachments for Electronic Claims sections of the Provider Manual for additional usage information.

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association:

Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Senior Health Company or Highmark Care Benefits Inc.

Central and Southeastern PA:Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.

Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.

West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company.

Western NY:  Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield.

Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to "Highmark" in this document are references to the Highmark company that is providing the member's health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.