EDI ERA Enrollment Form

Application for Highmark Blue Cross Blue Shield of Western New York and Highmark Blue Shield of Northeastern New York Electronic Remits

All fields are required except where marked (optional).

Provider Information

Provider Name – Name of individual or billing provider organization receiving remittance advice.

Provider Name

Provider Address

Provider Address – Mailing address of the provider or billing provider organization, including Street, City, State and ZIP Code.

Street City State/Province ZIP Code/Postal Code

Provider Identifiers Information

Provider Identifiers – Tax ID (EIN or SSN) and corresponding NPI (10 digits) of the billing provider. (Remittance Advice will be returned based on Billing NPI.)

Note: The Billing NPI can only be loaded under one Trading Partner ID for the ERA.

Provider Federal Tax Identification Number (TIN) or
Employer Identification Number (EIN) National Provider Identifier (NPI)

Other Identifiers

Other Identifier(s) – Assigning Authority – Administrative Services of Kansas (ASK)

Trading Partner ID – Enter your 7 digit trading partner number (will begin with either 0 or 6) assigned by ASK. This determines the Trading Partner Mailbox where the remittance advice will be delivered.

Assigning Authority

Trading Partner ID

Provider Contact Information

Provider Contact Name

Provider Contact Name – Provider office contact name.

Contact Telephone Number – Phone number of the contact name, including extension if available.

Email Address – Provider contact email address used to confirm ERA Enrollment to the provider.

Fax Number – Fax number of the contact name.

Contact Telephone Number Telephone Number Extension (optional) Email Address Fax Number (optional)

Electronic Remittance Advice Information

Preference for Aggregation of Remittance Data

Preference for Aggregation of Remittance Data – TIN and Billing NPI should match the information provided in Provider Identifiers Information. (Remittance Advice will be returned based on Billing NPI.)

This information can only be edited in the Provider Identifiers section.

Provider Tax Identification Number (TIN) National Provider Identification Number (NPI)

Electronic Remittance Advice Vendor Information

Vendor Name – Name of the software company that supports your practice management software.

Vendor Contact Name – Name of contact at the software company.

Telephone Number – Telephone number for the contact at the software company.

Email Address – Email address for the contact at the software company.

Vendor Name Vendor Contact Name Telephone Number Email Address

Submission Information

Reason for Submission

Reason for Submission – Check one box to indicate New Enrollment, Change Enrollment, or Cancel Enrollment.

New Enrollment

Change Enrollment

Cancel Enrollment

Authorized Signature

Authorized Signature – The name and title of the individual within the provider office authorized by the provider to initiate, modify or terminate an enrollment.

Print Name of Person Submitting Enrollment Print Title of Person Submitting Enrollment

For questions about this form, please call the EDI Help Desk at 1-800-472-6481, option 1.

Setup will be completed within 3-5 business days.
New Trading Partners must also complete the New Trading Partner Enrollment Form.

Reporting a Missing or Late Electronic Remittance Advice (ERA)

To report a missing or late 835 transaction (ERA), please contact the EDI Help Desk at 1-800-472-6481, option 1.

The following items are needed to track a missing electronic remit(s):

Trading Partner ID
Date of Check / EFT
Check / EFT Number
NPI on Check / EFT
Amount of Check / EFT

Kansas law applies to this business relationship.

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