Provider Information Management Forms

Provider Information Management forms are used to maintain provider accounts as well as begin the process to join Highmark's networks for new practitioners and offices. Practice information updates can be made with many of the forms below. Please carefully read and follow the instructions contained within the individual form for submission.

Highmark no longer requires a copy of the Medicare Welcome Letter for proof of Medicare eligibility for professional credentialing. 

Electronic Forms 

Electronic Forms are submitted directly to Highmark via this website.  You may need to upload documenation/provide additonal research during parts of this form.  Please feel free to take the time to research these items and input the responses as the form will not time out.  

  • 24/7 Coverage Form
    24/7 coverage is a requirement for participation in the Highmark Credentialed networks. Please complete this form to indicate how 24/7 coverage is provided by your practice.
  • Practice Address Addition Form for Professional Providers
  • Contract Upload Form
    Please only use this form to send Highmark a contract.  Other uploads will not be processed and not be returned.
  • Address Change Form For Professional Providers
  • Facility-Based Provider Affirmation Statement
    Please use this form when adding a practitioner to an existing assignment account when the services provided to members services by the networks are delivered exclusively in a participating skilled nursing facility, participating ambulatory surgery center, inpatient hospital and/or freestanding inpatient or outpatient facility setting and for members only because they are directed to the facility setting.
  • Hospital Privilege Update Form
    Please use this form if you want to add/update your hospital privileges.
  • Medication Assisted Treatment (MAT) Provider Form
    Please use this form to update your profile for Medication Assisted Treatment services in Highmark's networks. 
  • Opioid Treatment Certificate Update Form
    Please complete this form to add your Opioid Treatment Program Certificate to your provider file.  An Opioid Treatment Certificate is required to receive payment when providing services at Opioid Treatment Programs (OTPs) to deliver Opioid Use Disorder (OUD) treatment services.
  • Plan of Action for DEA Form
     A DEA is required for providers who prescribe controlled substances in each state where the provider provides care to its members.  Please use this form to indicate your DEA status.
  • Provider-Hosptial Affiliation Upload Form - Please use this form quarterly to upload your provider/hosptial affiliation data. 
  • Provider Change Form - In this form you will be able to change your Practitioner Name, Tax ID, Tax ID Name, DBA Name and NPI
  • Request for Assignment Account – Please use this form when you need to create a billing account for your practice.
  • Request for Addition / Deletion to Existing Assignment Account – Please use this form when needing to update practitioners affiliation to existing assignment account information.
  • Request to Terminate a Contracted Network 
    Please only use this form to terminate the following Highmark networks: All Commercial Networks, All Medicare Networks or All Medicaid Networks.
    This form may not be used to terminate an individual commercial network.  It may only be used to terminate the groups of networks listed above.
  • Specialty Change Form
    Please only use this form if the provider has been previously approved for credentialing and is linked to your Tax ID/NPI.  The practitioner must meet all current credentialing criteria in order for the request to be processed.

Provider Information Management Documents

Last updated on 10/27/2020

 

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