New Trading Partner Form

5010 EDI Transaction Application to Create New Trading Partner

All fields with (*) are required

Select the tabs on the left to fill out the information in those sections

Payer Information

Select the Highmark Company for which you are requesting a new EDI Trading Partner account

Highmark

[54771]

Highmark Delaware

[00570, 00070]

Highmark Western & Northeastern New York

[55204]

Highmark West Virginia

[54828]

Highmark Senior Health Company

[15460]

Highmark Senior Solutions Company

[15459]

If you reset the current Payer Information you will need to re-enter any information you may have already entered on this 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)	Inquiry (270/271, 276/277)	Prior Authorization (278, 275SR)	ERA (BX 835)
Highmark Western and Northeastern New York Inc. (55204)
Highmark (54771)
Highmark Delaware (00570, 00070)
Highmark West Virginia (54828)
Highmark Senior Health Company (15460)
Highmark Senior Solutions Company (15459)

Provider Information

Please fill in the appropriate provider-related fields and click the 'Add Provider' button to record the provider.

Group NPI#*

Provider Name*

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.

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.