New Electronic Provider Forms
In order to streamline our provider information management system and comply with the No Surprises Act (NSA) effective January 1, 2022, new provider change forms are now available. Please use these forms to ensure faster processing time.
- APP Enumeration Form
- This form should be used to enumerate Advance Practice Providers (APPs) in Highmark's reimbursement systems.
- Nurse Practitioner Agreement/Acknowledgement
- Attestation form for Nurse Practitioners that have a collaborating agreement with a Supervising Physician.
- Provider Directory Update Form
- (previously the Provider Demographic Change Form)
- Providers should utilize this electronic form to update name, address, phone number, email or web address, and specialty type for a practitioner or group OR to terminate a practitioner from a group.
- Supervision Data Form
- Attestation form for Physician Assistant/CRNA/Registered Nurse First Assist (RNFA) that have a collaborating agreement with a Supervising Physician. This form must be updated as a condition of practice.
- Tax ID Change Form
- This form should be used only to change your Tax ID. Please continue to bill claims as previously submitted until you receive confirmation that this form has been processed.
- Provider Website Feedback Form
We want to ensure that your online experience meets your needs.
Quality Compliance Forms
Behavioral Health Forms
- Functional Behavior Assessment Autism Comprehensive Evaluation Request Form
- Behavioral Health Clinical Criteria Set Request Form
- Behavioral Health Practitioner Questionnaire
- Behavioral Health Out-of-Plan Referral Review Request Form
- Chemical Dependency Outpatient Treatment Review (OTR) Form
- Mental Health Outpatient Treatment Review (OTR) Form
- Outpatient Applied Behavioral Analysis Treatment Report
- Transcranial Magnetic Stimulation (TMS) Request Form
Patient Care Forms
- Diabetic Retinal Exam Referral Form Use this form when completing Diabetic Retinal Exam Referrals
- Durable Medical Equipment Preauthorization Form
- Health Care Proxy Form The New York Health Care Proxy Law allows you to appoint someone you trust to make health care decisions for you if you lose the ability to make decisions yourself.
- Injectable Medication Prior Approval Medical Necessity Form This prior authorization is subject to all drug therapy guidelines in effect at the time of the approval and other terms, limitations and provisions in the member's contract/rider. We reserve the right to update and/or modify our drug therapy guidelines for prospective services.
- In-Network Referral Form Fillable form for fax use.
- Health Care Services Referral Form
- Home Health Care Preauthorization Form
- Lead Risk Assessment In addition to the state mandated required testing at ages one and two, assessment of risk for high-dose lead exposure should be done at least annually for each child six months to six years of age.
- Med D Coverage Determination Form A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.
- Out-of-Plan Referral Review Request Form
- Preauthorization Form Elective Surgery
- Preauthorization Form: Outpatient Services
- Preauthorization Form: Transplant
- Preauthorization/Non-Formulary Medication Request Form
- Disclosure of History Form
- Disclosure of Ownership and Control Form - Facility
- Disclosure of Ownership and Control Form - Practitioner
- Provider Enrollment Application Checklist
- New Provider Enrollment and Disclosure Form
- Primary Care Physician (PCP) Change Form This is a form that providers will supply to the patient/member when they are changing their PCP.
- Request to Resolve Provider Negative Balance
- Dental Provider Demographic Change Form
- Provider Claim Inquiry Form When submitting a provider inquiry for review, please submit all materials as indicated within the form.
Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.