Electronic Forms
Electronic forms are submitted directly to Highmark via this website. You may need to upload documentation/provide additional research during parts of these forms. Please feel free to take the time to research these items and input the responses, as the forms will not time out. Failure to provide necessary information may delay the credentialing process.
The credentialing forms listed below are available and should be used to provide Highmark with needed credentialing information, as well as information to maintain Professional and Facility/Ancillary (Organizational) Provider accounts.
Please carefully read and follow the instructions contained within the individual form for submission. If you are unsure of which form to use:
- CLICK HERE for Professional Provider accounts
- CLICK HERE for Facility/Ancillary (Organizational) Provider accounts
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Change of Ownership (CHOW) Form – This form is for Facility and Ancillary Providers to report any changes in ownership, which may include the Legal Name, Doing Business As name, NPI, or Tax ID information.
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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.
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Highmark Facility/Ancillary Change Form – Please use this form to update addresses, 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.
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Hospital Privilege Update Form – Please use this form to add/update a credentialed provider’s hospital privileges.
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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.
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Leave of Absence Form – Please complete this form when the provider is leaving or returning from a leave of absence. This will allow for the reinstatement of network participation.
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Provider-Hospital Affiliation Upload Form – This form is used on a quarterly basis to upload a provider’s provider/hospital affiliation data.
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ADDITIONAL FORMS
Additional Provider Information Management Forms can be found HERE.
Last updated on 5/31/2023 2:23:17 PM