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. 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 documentation/provide additional 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.  

>> Provider Directory Update Form
Providers should utilize this electronic form to update a practitioner or group name, address, phone number, email, website address, and specialty or to terminate a practitioner from a group. This form has been created for in-network provider use in order to comply with the No Surprises Act that was signed into law in December 2020.  Changes to these elements will not be accepted via any other electronic form.

  • 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.
  • Request for Assignment Account – Please use this form when you need to create a billing account for your practice.
  • Addition Request to Existing Assignment Account – Please use this form when needing to update practitioners affiliation to existing assignment account information.
  • Advanced Practice Provider (APP) Enumeration Form
    This form is used to enumerate Advance Practice Providers (APPs) in Highmark's reimbursement systems.
  • Contract Upload Form - Please only use this form to send Highmark a contract. Other uploads will not be processed and not be returned.
  • 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.
  • Highmark Facility/Ancillary Change Form
    Please use this form when needing to update address, phone numbers and contact information to existing locations for UB Facility Billers, Urgent Care Centers/Medical Aid Unit/Retail Clinics, or for Organizational Behavioral Health Billers.
  • 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.
  • Pharmacist Enumeration Form
    Use this form to enumerate West Virginia Pharmacists in Highmark’s reimbursement
  • 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-Hospital Affiliation Upload Form - Please use this form quarterly to upload your provider/hospital 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 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.
  • West Virginia Medicaid Screened Form - Please only use this form when you have previously applied to the West Virginia Family Health Network and were notified by Highmark that you did not complete the DXC Technology Screening Process but have since completed it.
  • West Virginia Pharmacist Enumeration Form - Please use this form to enumerate West Virginia Pharmacists in Highmark’s reimbursement systems.

Provider Information Management Documents

Last updated on 4/4/2022 10:54:34 AM

 

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