As of January 1, Highmark Wholecare no longer requires prior authorization for over 200 services. This move is meant to reduce administrative burden for our provider network. The listing of affected Medicare and Medicaid services can be found here.
The Highmark Wholecare Provider Newsletter has been replaced with the Provider News monthly email. The Provider News email will become our primary communications channel, allowing us to consolidate and simplify updates for you each month. Subscribe here to stay up-to-date with Highmark Wholecare member programs, provider policies, claims, reimbursement, and more!
Providers now have access to a new Clinical Platform, GuidingCare. This platform allows access to an Authorization Portal via NaviNet. Please utilize this online capability as the preferred method to submit your authorization requests. To learn more about accessing this new platform, please review the provider guide here.
There are members who may still be eligible for Medicaid but are being disenrolled due to failure to renew or provide the required documentation. To assist with identifying affected patients, please view the expanded PCP Medical Assistance (MA) Renewal Report in our provider portal, via NaviNet. Additionally, this flyer (English, Spanish) can help patients who have been disenrolled from Highmark Wholecare Medicaid coverage.
Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. 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.
Highmark adheres to the Centers for Medicare and Medicaid Services (CMS) coverage determinations for Medicare Advantage (MA) membership. You're being redirected to the CMS search site.