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
HEDIS Measure Changes
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
- Mental Health Outpatient Treatment Review Form
- Chemical Dependency Outpatient Treatment Review (OTR) Form
- Outpatient Applied Behavioral Analysis Treatment Report
- Transcranial Magnetic Stimulation (TMS) Request Form
Patient Care Forms
- Durable Medical Equipment Preauth form This form is used to request a Prior Authorization for Durable Medical Equipment (DME)
- 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.
- Home Health Care Preauthorization Form
- In-Network Referral Form Fillable form for fax use.
- 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.
- Out of Plan Referral Review Request Form This form is used to request an Out-of-Plan Referral also referred to as an Out-of-Network Referral, for services outside of the Servicing Network.
- Preauthorization Form: Elective Surgery
- Preauthorization Form: Outpatient Services
- Preauthorization Form: Transplant
- Preconception Checklist
- Provider Office Accident Questionnaire This form is used to assist in determining if a patient is eligible to receive Workers' Compensation, No-Fault Automobile or Personal Liability insurance benefits due to a possible accident or injury.
- Health Care Services Referral Form To refer a patient who is a BlueCross BlueShield member to our disease management, case management or health coaching service, complete and fax this form to the number enclosed.
- Vaccine Claim Form – Part D Member This claim form is for reimbursement of covered Part D vaccines and their administration (injection). This form is for Providers to give to members if necessary. If requested, please ask that they check their Evidence of Coverage for specific coverage information.
- Preauthorization / Non Formulary Drug Request Form
- Medicare Diabetes Prevention Program Referral Form
- Request For Medicare Prescription Drug Coverage Determination ,
- 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 & Disclosure of Ownership Control
- 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.