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Miscellaneous Forms

On this page, you will find some recommended forms that providers may use when communicating with Highmark, its members or other providers in the network.

Appeals Forms

Notice of Medicare Non-Coverage (Medicare Advantage Members)

Here you will find the Notice of Medicare Non-Coverage (NOMNC) form that skilled nursing facilities, home health agencies and CORFs must deliver to Medicare Advantage patients no later than two days before services will end.

Detailed Notice of Discharge (Medicare Advantage Members)

Last updated on 4/15/2024 11:53:49 AM

 

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Legal Information

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

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 and/or to one or more of its affiliated Blue companies.