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Request Change to Existing FISS/HIQA Logon Form for NJ Providers Print

In accordance with the CMS security policy, the FISS Logon ID is not to be used by any one other than the assigned user. Highmark Medicare Services requires that every user of the Fiscal Intermediary Standard System (FISS) must have a unique Logon ID for greater accountability and security. The password is not to be revealed to anyone, including Supervisors and Managers.

If at any time you believe someone has used your Logon ID, complete this form to have the ID suspended immediately and then use the Form to Request a Medicare Part A Logon ID to have a new one established.

Effective June 1st it is CRITICAL that all logon requests submitted to Highmark Medicare Services have the REQUESTORS e-mail address and phone number on the request form or change form. No longer will logon request information be sent to managers, supervisors or persons other than the REQUESTOR. The requestor and ONLY the requestor will now receive the logon information directly.

Provider Information

Provider Name

Provider Number

Your Address

Current Medicare Part A Logon ID

PIN

Select ONE of the following Changes

Add Provider Number(s) Enter the provider number(s) for this Logon ID to be able to view and correct claims for

Add FISS to Existing Logon
Enter the Detailed Business Purpose for accessing FISS

Remove Enter Logon to be Removed

Date Last Accessed Enter the date last accessed for the logon you wish to be removed
Requestor's Information

Requestor's Name Enter First Name, Middle Initial, Last Name

Telephone Number

E-Mail Address (Required)

Requestor's title

Supervisor's Full Name

Supervisor's Phone Number

By submitting this form you are agreeing to the following:

  • I understand the responsibility to protect and maintain the confidentiality of the data
  • I also understand that if the Medicare data obtained from the FISS is mishandled in any way, I will be held responsible in accordance with Medicare requirements.

I have read the above agreement and attest to the truth of all information submitted herein.

    
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