WebBy signing this Provider Form, we are agreeing to the Highmark Provider Form Regulations (version 1.0) found on the Provider Resource Center at www.highmark.com. Signature of Authorized Representative of Group Date ( ) Title Telephone Number Please fax the completed form to: Provider Information Management at (800) 236-8641 Webclinical information that will support the present diagnosis(es) and treatment plan to: 1-888-492-1025. For a complete list of services requiring authorization, please access the Physical Medicine Management Program Administrative Guide on the Highmark Provider …

Provider Resource Center

Web2 HIGHMARK PROVIDER MANUAL Chapter 3.2 Page. Provider Network Participation: Professional Provider Credentialing . 3.2 INTRODUCTION TO CREDENTIALING . Overview . Where the Highmark professional provider networks are utilized to support managed care products, Highmark must credential providers and utilize http://highmarkbcbs.com/ pools by ricketts

Provider Resource Center

WebHighmark Clinical Services Referral Form Highmark Facility/Ancillary Change Form Home Health Precertification Worksheet Inpatient Authorization Request Form Interpreter Needed - Language Translation Sign for Provider Offices Long-Term Acute Care Facility Precertification Form Medical History Form(Preexisting Condition Form) WebProvider Name: Member Name: Provider Street Address, City, State, ZIP: Member ID Number (Including Prefix): Provider NPI: Member Group Number: Provider Tax ID: Claim Number: Date of Service: Mail all inquiries to: Highmark Blue Shield of Northeastern New York WebMar 29, 2024 · The following forms are available in a simple and convenient digital submission format. These forms will help reduce processing time and administrative burden for your office: Provider Directory Update Form* (previously the Provider Demographic Change Form) Tax ID Change Form**. Nurse Practitioner Agreement/Acknowledgement. … shared dating