Provider Information Management Forms

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. 

Credentialing Forms

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.

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.

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.

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.

Hospital Privilege Update Form - Please use this form if you want to add/update your hospital privileges.

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

Leave of Absence Form - Please complete this form when a provider is beginning or returning from a leave of absence. This will allow for the reinstatement of network participation

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 members. Please use this form to indicate your DEA status.

Provider-Hospital Affiliation Upload Form - This form is used on a quarterly basis to upload a provider’s provider/hospital affiliation data.

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 Form

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 Provider Information Management Forms

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.

Request for New Practice (Assignment Account) - Use this form when you need to create a billing account for your practice.

Request to Add a New Practitioner to Existing Practice - Use this form when needing to update practitioner’s affiliation to an existing participating practice (Assignment Account).

APP Enumeration - This form is used to enumerate Advanced 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.

Name Verification Form - Use this form if a practitioner's name on any document is different than what appears on their current medical license. They may also update the information in the Other Names section of their CAQH profile.

Provider Change Form - In this form you will be able to update your NPI and/or license.

Facility-Based Provider Affirmation Statement - Use this form when adding a practitioner to an existing assignment account when the services provided to members are delivered exclusively in a participating skilled nursing facility, participating ambulatory surgery center, inpatient hospital, and/or freestanding inpatient or outpatient facility setting.

Out of State Address Change Form for Professional Providers - This form should be used for providers outside of Delaware, New York, Pennsylvania, and West Virginia to create a billing vendor or to update an address on an existing billing vendor.

Request to Terminate a Contracted Network - Only use this form to terminate the group contract from 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.