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9101 (R10-12) Page 1 of 3
Highmark Provider Form
Please read the instructions below before completing this form, and mark a box for each action taken. Please note that this
form may be used for providers of Highmark Inc. (“Highmark”) and certain affiliates: Highmark West Virginia Inc.
(“Highmark WV”), Highmark Health Insurance Company (“HHIC”) and Highmark BCBSD Inc. (“Highmark DE”).
ALL requests must complete Sections 1 AND 6.
Adding or deleting a provider? Complete Sections 1, 2, 3 AND 6.
Changing a main/practice/check/mailing address? Complete Sections 1, 3 AND 6.
Changing a group name/DBA name/Tax ID? Complete Sections 1, 5 AND 6.
Creating an Assignment Account (PA or DE) or Pay-To Account (WV)? Complete Sections 1, 2, 3, 4, AND 6.
SECTION 1 – Please complete for all requests.
Name of Account (DBA name)
Tax ID (Provide copy of Federal IRS Notification. W-9 is NOT acceptable.)
Type 2 (Group) National Provider Identifier (NPI) Highmark Group Number
SECTION 2 – Please complete if adding or deleting a practitioner. (Note: For NaviNet users, changes should be made online.)
If a practitioner needs
to be credentialed, log on to the Provider Resource Center at www.highmark.com under
“
Provider Applications” and complete the “CAQH ID Request” to start the process.
Effective date of addition/change
Practitioner Name
Date of Birth
CAQH ID
Type I NPI (Individual)
Practitioner
Add
Delete
SECTION 3 – Please complete for address changes or additions. (Note: For NaviNet users, changes should be made online.)
Add Change Main Practice address Add* Change Delete Practice address(es)
Effective date of addition/change
Add Change Check address Add Change Mailing address
Main Practice Address – Primary physical practice location (PO Box numbers are NOT acceptable)
Practitioners at this location:
Telephone number: ( )
Fax number: ( )
Member Access Number:
( )
Patients call this number to make
an appointment for this location
Office hours
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Practice Address 1 – physical location where patients receive services Practitioners at this location:
Telephone number: ( ) Fax number: ( )
Office hours
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Practice Address 2* – physical location where patients receive services Practitioners at this location:
Telephone number: ( ) Fax number: ( )
Office hours
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
* Use a separate sheet for additional practice addresses.
Mailing Address – if different than Main Practice and Check Address Check Address – where checks are sent
Is this a lockbox? Yes No
Telephone number: ( ) Telephone number: ( )
Fax number: ( ) Fax number: ( )
9101 (R10-12) Page 2 of 3
SECTION 4 – Please complete if requesting an Assignment Account (PA or DE) or a Pay-To Account (WV).
If a practitioner needs to be credentialed, log on to the Provider Resource Center at www.highmark.com under “Provider Applications”
and complete the “CAQH ID Request” to start the process.
Is this request for: School-based clinic? Rural Health Clinic (RHC)? Federally Qualified Health Clinic (FQHC)?
Urgent Care Facility/ Retail Clinic Entities only
Please indicate if the requesting entity is: Urgent Care Facility OR Retail Clinic
Legal Entity Requesting Account – Please check one:
Sole Proprietorship
Partnership (General)
Partnership (Limited)
Non
-
Profit Corporation
Business Corporation
Professional Corporation
Limited Liability Partnership
Limited Liability Company
(including restricted professional companies)
Health Care Facility
Other
(explanation must be provided)
Relationship Between Legal Entity and Provider – Please check one:
Employed Relationship
Solo Practitioner
Member/Shareholder
Group billing under a Health Care Facility Tax ID
General Partner
Other
(explanation must be provided)
Does the group employ CRNAs? Yes No If YES, complete the “CRNA Employment Status” on the Provider Resource Center at
www.highmark.com and return.
Do you currently participate in QualityBLUE under another vendor affiliation? Yes No
If you are currently billing with another Assignment Account (PA or DE) or Pay-To Account (WV), will you be terminating that account?
Yes No If YES, when? _________________________ (date)
Highmark ID of terminated Assignment Account (PA or DE) or Pay-To Account (WV): _________________________
If terminating an Assignment Account (PA or DE) or Pay-To Account (WV), are you still available to members at another location?
Yes No
If YES, name and address of new location? ___________________________________________________________________________
Effective date of new location? __________________________ (date)
If NO, please note that members will be notified of your network termination from the above-terminated group.
NaviNet Contact Information – Please provide the name of your office staff that is responsible for NaviNet:
NaviNet Contact Name:
Telephone number: ( )
Email address:
Do you currently have NaviNet with Highmark, Highmark WV, Highmark DE and/or HHIC or any other health insurance carrier?
Yes No
If YES, please provide your NaviNet Username: ____________________________________ This information will be used to link your
new number to your current NaviNet set up.
SECTION 5 – Please complete for group name / DBA name / Tax ID changes.
Provider Name Change
New name of group account:
Effective Date:
DBA Name Change
Existing DBA name:
New DBA name:
Effective Date:
Tax ID Change
Existing Tax ID:
New Tax ID
Effective Date:
NPI Change
Existing NPI:
New NPI:
9101 (R10-12) Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association Page 3 of 3
SECTION 6 – Please complete for ALL requests. Please have the Authorized Representative sign below.
1. We hereby agree to only bill those services performed by providers in our account.
2. We certify that each member agrees to assign his/her fee to the group account.
3. We agree that every 1500 claim form submitted will include the provider number of the individual provider who actually
performed the service (place in Block 24K of the claim or in any other location as determined in the future).
4. We agree that the group and each individual provider member will be jointly and severally liable for any overpayment that the
group receives.
5. We agree to notify Highmark, Highmark WV, Highmark DE or HHIC (as each may be applicable) in writing of any subsequent
changes in the composition of the group prior to the effective date of each change.
6. We agree to inform Highmark of any change in the group’s contractual arrangements that directly or indirectly impact this
Assignment Account (PA or DE) or Pay-To Account (WV) or that would necessitate Highmark, KHPW, Highmark WV, Highmark
DE or HHIC payments to be made to some entity other than that designated in this Assignment Account (PA or DE) or Pay-To
Account (WV) application.
7. [For PA providers only] We certify that we will not bill for any professional services that are reimbursed through another
Pennsylvania Blue Cross Plan. All claims for these services will be submitted on the 1500 claim form for all appropriate Blue
lines of business patients.
8. We understand that for certain networks all individual providers in the group must be fully credentialed in order for the group
to be able to bill directly for that network and before rendering services to members.
9. We have carefully reviewed the forms and applications associated with the establishment of this agreement and each member
has verified the accuracy and completeness of all information provided.
10. We have carefully reviewed the Highmark Provider Form and each member certifies and represents that the requested account
will satisfy the requirements, and when established, that the account will not represent an ineligible arrangement as described
in Part III of the Highmark Provider Form Regulations.
On behalf of the group, I certify that all providers have reviewed and agree to be bound by the Highmark Provider Form
Requirements. I represent and warrant I have the authority to bind the individual providers and sign on their behalf.
By signing this Provider Form, we are agreeing to the Highmark Provider Form Regulations (version 1.0) found on the Provider
Resource Center at www.highmark.com.
Signature of Authorized Representative of Group Date
( )
Title Telephone Number
Please fax the completed form to:
Provider Information Management at
(800) 236-8641
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Completed 24 June 2021

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