February 2026

Model of Care

Highmark Wholecare providers are required to complete and attest to Model of Care (MOC) training on an annual basis. The training focuses on the SNP Provider Network section and outlines what is expected from providers to maintain an effective MOC in the new year.

Promoting Quality

Annual HEDIS Medical Record Review

Highmark Wholecare is conducting the annual HEDIS medical record review for 2025 until April, as required by the National Committee for Quality Assurance. Please remember to respond to and submit necessary information when requested for this process.

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Policy Updates

Prior Authorization and Medical Policy Updates

Regularly check the Highmark Wholecare Provider Resource Center (PRC) for a list of procedure codes added to the Highmark Wholecare Medicaid and Medicare Prior Authorization List (PAL) that require prior authorization.

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Program Launch

HWPE Incentive Program Launch

The 2026 Highmark Wholecare Practitioner Excellence (HWPE) Incentive Program launches on Monday, March 2, 2026! Beginning in March, you are invited to attend a live webinar to answer any questions you have about the program. Visit the PRC to learn more about opting in and participating.

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Annual Training

Provider Fraud, Waste, and Abuse (FWA) Training

Highmark Wholecare's Financial Investigations and Provider Review (FIPR) Division will be hosting a live provider FWA training webinar on Wednesday, April 8, 2026 from 12:00 p.m. – 1:00 p.m. Register now to secure your spot for the annual training.

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Important information

Reportable Conditions

Post-Acute Care Management: Authorization Process Changing

Screening for Substance Use Disorder

Universal Blood Lead Toxicity Testing

Provider Self-Reported Recovery

Medicaid OB providers and PCPs who Provide Maternity Care

Medicare Parts A and B Cost-Sharing

The Provider News email is sent at the end of each month to share simple and consolidated updates about Highmark Wholecare member programs, provider policies, claims, reimbursement, and more.

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For Your Reference

• Notice of Practice/Practitioner Changes

• Cultural Competency Data Form

• Encounters Submissions

• Important Phone Numbers

The information in this newsletter is for Highmark Wholecare providers. For updates specific to Commercial and Medicare Advantage in Western or Northeastern PA, or Central or Southeastern PA, click here.

This information is issued on behalf of Gateway Health Plan, Inc. d/b/a Highmark Wholecare, an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare provides Medicaid coverage for Blue Shield in 14 counties in central PA and Blue Cross Blue Shield in 14 counties in western PA. Highmark Wholecare provides Medicare Dual-Eligible Special Needs Plans (HMO D-SNP) for Blue Shield in 17 counties in northeastern PA, 13 counties in central PA, 5 counties in southeastern PA, and for Blue Cross Blue Shield in 27 counties in western PA. Highmark Wholecare offers HMO plans with a Medicare Contract. Enrollment in these plans depends on contract renewal.

Highmark Wholecare, 120 Fifth Ave., Pittsburgh, PA 15222

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