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Effective December 1, 2025, there will be updates to the PA Medicaid Prior Authorization List (PAL). Please click to visit our Prior Authorization Code Lookup page to view these important updates.
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Effective January 1, 2026, the timely filing for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) claims will be changing. EPSDT claims must be received within 90 days of the date of service to be considered timely. Claims received outside of the 90-day timeframe will be denied for being outside of timely filing. This change is being implemented due to PA DHS requirements.
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Use the SSBCI Provider Attestation form to support your Wholecare Dual Eligible patients in qualifying for extra benefits to support their health, like money for healthy food and utility payments.
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Providers cannot bill a Medicaid member for covered services (excluding copays) & must accept the Plan’s payments as payment in full. A member cannot be denied service if unable to pay copay. Our Medicare Assured members shall not be held liable for Parts A & B cost sharing when the appropriate Medicaid agency is liable. Federal law prohibits balance billing a dual eligible for deductible/coinsurance/copay.
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The 2025 Annual Provider Education and Orientation Training is now available on-demand and can be viewed at your convenience! The training provides current information to help you care for our Highmark Wholecare members on topics like claims, prior authorization, self-service tools, Model of Care, and more.
