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. 

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.
  • Adding a Practice Address
  • 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
  • Hospital Privilege Update Form
    Please use this form if you want to add/update your hospital privileges.
  • 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.
  • PROMISe Id Update Request  
    Please complete this form to add your PROMISe Id to your provider file.  PROMISe Id's are needed for each location where the provider practices; they are also needed for each location of the practice.  A PROMISe Id is required to receive payment when treating CHIP members.
  • 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 new a Highmark billing number.
  • 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.
  • Speciality 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 7/2/2019

 

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