Update TP Administrator/Delegate Form

Highmark BCBS/Highmark BS
Adaptive Form Title
Update Administrator/Delegate
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Update Administrator/Delegate
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Update Trading Partner Administrator/Delegate

All fields with (*) are required

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

Trading Partner Information

Trading Partner Number*

Reason For Deletion*

Validation Result Message [initially hidden; shown when needed]

TP Number placeholder [always hidden; set into Confirmed TP Number when Confirm button clicked]

TP Name placeholder [always hidden; set into Confirmed TP Name when Confirm button clicked]

TP Organization Code placeholder [always hidden; set into Confirmed TP Organization Code when Confirm button clicked]

TP Organization Description placeholder [always hidden; set into Confirmed TP Organization Description when Confirm button clicked]

Results for TP

Trading Partner Name:

Payer Name:

Type:

BX 835 Enabled? [Only visible when on BX 835 Enrollment form]

If this is the Trading Partner you wish to update, you must select Confirm to continue or you may Re-Enter a different Trading Partner number.

If you click the Re-enter button you will need to re-enter any information you may have already entered on this form.

Confirmation Message [initially hidden; shown when needed]

If you need to have your Trading Partner Name updated, please click the highlighted text.

Request Type*

Update Administrator

Add Delegate

Update Delegate

Delete Delegate

All requests must be submitted by the Trading Partner Administrator, except when a Delegate uses Update Delegate to add his or her own security question/answer pair.

Administrator Information

Your Name*

Your Title*

Your Company Name*

Your Telephone Number

Extension

Your Email Address*

For security purposes, EDI Operations will contact you and use your security question and answer to confirm your identity.

The Trading Partner Administrator can identify an additional Trading Partner Delegate who may act on the trading partner's behalf to request basic changes or information for this trading partner. An existing Trading Partner Delegate may update the Delegate Information to provide a security question/answer that will streamline your future EDI support.

Delegate Information

Delegate Name

Delegate Title/Function

Delegate Telephone Number

Delegate Email Address

FOR DELEGATE USE ONLY: In order to confirm your identity for security purposes, please choose one of the following security questions and provide your corresponding security answer. The security answer will enable us to more quickly provide you with trading partner support and information.

Security Question

Your Security Answer

Additional Comments

Please use this space for additional description or instruction

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.