Organizational Credentialing

Highmark continually seeks ways to make its network credentialing process easier for our providers. We are required by federal law and the American Accreditation HealthCare Commission to initially credential providers who participate in Highmark's preferred provider networks and in Highmark's Medicare Advantage network.

To begin the credentialing process, Organizational (Facility/Ancillary) Providers are expected to complete the Initial Application for Facility and Ancillary Providers.

• Highmark credentials Organizational (Facility/Ancillary) Providers at each location. When an existing entity is adding a new location, the new location must be credentialed before network participation.

• Organizational Provider Participation, Credentialing and Contracting Requirement
  
• Highmark Provider Manual Chapter 3, Unit 4
• Urgent Care Center/Medical Aid Unit and Retail Clinic Application

The following specialties are currently closed to network enrollment except New York networks and Delaware Medicaid:

• Skilled Nursing Facilities*
• Home Health Agencies*
• Durable Medical Equipment*
• Orthotics & Prosthetics*
• Laboratories

*Skilled Nursing Facilities, Home Health Agencies, Durable Medical Equipment, and Orthotics & Prosthetics specialties are open for initial credentialing for all New York networks and Delaware Medicaid.

Highmark performs outreach in the provider community when such services are determined to be a need. While closed network applicants are rarely considered, we do provide an option for special consideration. This process occurs before credentialing can begin.

Interested providers can complete the form below:

Special Consideration Questionnaire

For help identifying Behavioral Health Organizational Providers, read the Highmark Provider Manual Chapter 4, Unit 2: Behavioral Health Providers, section 4.2 Levels of Care.

Please use the following to help you start the credentialing process:

• Behavioral Health Application For Organizational Providers - This application is to be used by organizational providers only. Professional providers should select Provider Network in the top navigation bar, then Professional Credentialing.

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.

Highmark Facility/Ancillary Change Form - 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.

Initial Application for Facility and Ancillary Providers - To begin the credentialing process, Organizational (Facility/Ancillary) Providers are expected to complete this form.

Behavioral Health Application For Organizational Providers - This application is to be used by organizational providers only. Professional providers should select Provider Network in the top navigation bar, then Professional Credentialing.

Urgent Care Center/Medical Aid Unit and Retail Clinic Application - For questions related to this application, please refer to the Highmark Provider Manual, Chapter 3.4.

Recredentialing Application for Facility and Ancillary Providers - If you have recently received a letter stating that you must recredential, please use this form to enter the requested information.

Additional forms are available on the Provider Information Management Forms page.

Additional Resources for Providers

• Provider Information Management (PIM) Glossary
• Highmark Provider Manual - See Chapter 3 for detailed information on Provider Network Participation.
• What to Expect During Initial Organizational (Facility/Ancillary) Credentialing
• What to Expect During Organizational (Facility/Ancillary) Recredentialing