Provider Resource Center

[{"id":453,"versionId":5,"title":"Hepatitis B and Hepatitis C Training Banner","type":4,"subType":null,"childSubType":"","date":"7/9/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/450/Free-Hepatitis-B-Hepatitis-C-Training-for-Perinatal-Pediatric-Providers\"\u003e\u003cstrong\u003eTraining Opportunity for Perinatal and Pediatric Providers:\u003c/strong\u003e\u003c/a\u003e A free webinar outlining prenatal and pediatric Hepatitis B and Hepatitis C best practices will be held on July 17 from 1:00-2:30 p.m. Click \u003ca href=\"https://www.maaetc.org/events/view/26427\"\u003e\u003cstrong\u003ehere\u003c/strong\u003e\u003c/a\u003e to register!\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":434,"versionId":5,"title":"Clinical Services Referral Guide","type":4,"subType":null,"childSubType":"","date":"6/10/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eHighmark Wholecare has developed a robust offering of clinical programs that offer whole person care to our members and improve health outcomes. We are excited to share that the updated \u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/ClinicalServicesReferralGuide.pdf\"\u003e2024 Clinical Services Referral Guide\u003c/a\u003e\u0026nbsp;is now available for providers to review the programs accessible to their Highmark Wholecare patients.\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":392,"versionId":5,"title":"UM Transitions","type":4,"subType":null,"childSubType":"","date":"3/26/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003e\u003cstrong\u003eImportant UM Authorization Updates:\u003c/strong\u003e\u0026nbsp;Effective May 1st, there\u0026nbsp;are updates to the authorization requirements and processes for various Highmark Wholecare services. To learn more about these specific changes and to review reference materials, visit the following links:\u003cstrong\u003e \u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/391/New-Authorization-Requirements-for-Musculoskeletal-Pain-Management-Diagnostic-Imaging-and-Physical-Medicine\"\u003eMusculoskeletal/Pain Management, Diagnostic Imaging and Physical Medicine\u003c/a\u003e;\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u0026nbsp;\u003cstrong\u003e\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/390/New-Authorization-Process-for-Family-Planning\"\u003eFamily Planning\u003c/a\u003e;\u0026nbsp;\u003c/u\u003e\u0026nbsp;\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/389/New-Authorization-Requirements-for-Cardiology\"\u003eCardiology\u003c/a\u003e\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":356,"versionId":5,"title":"Prior Authorization Updates","type":4,"subType":null,"childSubType":"","date":"2/12/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003e\u003cstrong\u003e\u003cspan\u003eEffective 7/1:\u003c/span\u003e\u003c/strong\u003e\u003cspan\u003eServices requiring prior authorization from Highmark Wholecare\u0027s UM Department must be submitted through the GuidingCare portal in Navinet. If the portal is unavailable, you can call our UM team at 1-800-392-1147 TTY: 711 or fax the request using \u003cstrong\u003e\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/378/UM-Fax-Number-Changes\"\u003eUM fax numbers\u003c/a\u003e\u003c/u\u003e\u003c/strong\u003e. Shift care providers and services requiring authorization through HealthHelp \u0026amp; OncoHealth will continue to follow the current process.\u003c/span\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":289,"versionId":5,"title":"E-Subscribe Provider Website Banner","type":4,"subType":null,"childSubType":"","date":"12/6/2023","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eThe Highmark Wholecare Provider Newsletter has been replaced with the \u003cstrong\u003e\u003cem\u003eProvider News\u003c/em\u003e monthly email\u003c/strong\u003e. The \u003cem\u003eProvider News\u003c/em\u003e email will become our primary communications channel, allowing us to consolidate and simplify updates for you each month. \u003ca href=\"https://wholecare.highmarkprc.com/e-Subscribe-for-Publications-and-Notifications\"\u003eSubscribe here\u003c/a\u003e to stay up-to-date with Highmark Wholecare member programs, provider policies, claims, reimbursement, and more!\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2}]

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5/21/2024

Clinical Practice and Preventive Health Guidelines

Highmark Wholecare believes in providing the best possible health care to our members. That is why we follow clinical practice and preventive health guidelines. These guidelines are based on the latest clinical practice guidelines from professionally and industry-recognized sources or through the experience of board-certified practitioners from appropriate specialties when guidelines are not available. They help guide our practitioners in providing consistent, high-quality health care for specific conditions relevant to our members. Providers are encouraged to review these applicable guidelines. They are not meant to replace the clinical judgement of our providers, but instead to support you in making informed decisions about the best care for our members.

Before we put these guidelines into practice, they are reviewed and approved by Highmark Wholecare’s Quality Improvement and Utilization Management Committee.

Examples of some of the guidelines include:

Pediatric Preventive/EPSDT/Lead Screening (Birth to 21 Years)
Adult Preventive Care
Asthma
Attention Deficit Hyperactivity Disorder (ADHD)
Bipolar
Cardiac Medical Management
COPD
Cystic Fibrosis
Depression
Diabetes
HIV
Hypertension
Major Depression in Adults in Primary Care
Opioid Prescribing for Chronic Pain
Healthy Weight Management
Healthy Weight Management in Children and Adolescents
Palliative Care
Routine and High Risk Prenatal Care
Preventive Dental Care
Schizophrenia
Sickle Cell Disease
Substance Use Disorder

A complete listing of the Medicaid and Medicare guidelines are available on our provider website. Guidelines can be printed from the website or to receive a paper copy, call Provider Services at 1-800-392-1147 (Medicaid) or 1-800-685-5209 (Medicare). TTY users dial 711.

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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.

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