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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7/15/2024

Highmark Wholecare Policy Updates

Highmark Wholecare regularly reviews and updates our policies and procedures. To help you know when policies have been amended, we post a Provider Notice to our website one month (30 days) prior to the effective date. You can find these Provider Notices on the first of each month at the following links:

Medicaid Provider Updates

Medicare Provider Updates

Policy Updates Effective August 1, 2024

As a reminder, we have updated or reviewed the following Medical Policies, with changes effective August 1. These updates were previously posted on the Highmark Wholecare provider website July 1, 2024.

Medicaid Policies:

MP-072-MD-PA Ambulance Services – Ground - No changes to criteria. Updated ‘Reference Sources’ section.

Medicare Policies:

MP-099-MC-PA Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (L34636) - No change to clinical criteria. Updated CMS hyperlinks. Under ICD-10-CM Codes, Group 1, 2, and 3, three codes were deleted. Additionally, a number of codes were added in these groups, per CMS guidance.
MP-067-MC-PA Peripheral Venous Ultrasound (L35451) - The medical policy title changed from “Non-Invasive Peripheral Venous Studies (L35451)” to “Peripheral Venous Ultrasound (L35341)”. Removed the various CPT codes. Added and removed the various ICD-10 codes, all per CMS guidance.
MP-075-MC-PA Ambulance Services (Air) - No changes to clinical criteria. Updated ‘Reference Sources’ section.
MP-036-MC-PA Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) - No changes to clinical criteria. Updated ‘Summary of Literature’ and ‘Reference Sources’
MP-080-MC-PA Cosmetic and Reconstructive Surgery (L35090) - No changes to clinical criteria. Updated ‘Reference Sources’ section.

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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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