December 2025

Reflecting on a Year of Member Care

It’s time to reflect on a year of meaningful progress, made possible through the dedication of our Highmark Wholecare Provider network. Through improving communication and care coordination, and enhancing member safety while supporting healthier lifestyles, together we can continue to deliver remarkable care in the year to come.

Process Update

Post-Acute Care Management: Authorization Process Changing

Starting March 1, 2026, Highmark Wholecare is simplifying post-acute care authorizations for D-SNP members by moving to the Guiding Care platform. This change will streamline submissions for providers in various facilities, accessible via NaviNet.

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Patient Resources

Reminder: SSBCI Qualification Requirement for Highmark Wholecare D-SNP Members in 2026

Highmark Wholecare is offering additional benefits to it’s SSBCI-eligible members, and many are already qualified based on claims history and risk analyses. You can help remaining members gain access to these benefits more quickly by completing the SSBCI Provider Attestation Form upon patient request.

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Promoting Quality

Annual HEDIS Medical Record Review

Highmark Wholecare will conduct its annual HEDIS medical record review for 2025 from January through 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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Patient Resources

Ensuring Clear Communication with Members: Language Access Resources

It’s important to support patients who speak different languages by using the interpreter services and tools available to you. Learn how to access these resources to ensure all Highmark Wholecare members receive the clear and effective communication they deserve.

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Important information

Osteoporosis Management in Women (OMW): A HEDIS Focus

Important Billing Reminders for Lab Orders from Multiple Ordering Sources

Tobacco, Alcohol and Drug use Assessment

Reminder: Appropriate Use of JW and JZ Modifiers

Streamline Care Gap Management with the 2025 CGMA

Invitation to Participate- Individualized Care Plan (ICP) and Interdisciplinary Care Team (ICT)

2026 EVV Compliance Enforcement for Home Health Providers

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

• Policy Updates

• Notice of Practice/Practitioner Changes

• Please Complete the Cultural Competency Data Form

• Encounters Submissions

• Medicare Parts A and B Cost-Sharing

• Model of Care Training Summary

• Important Phone Numbers

The information in this newsletter is for Highmark Wholecare providers. For updates specific to Commercial and Medicare Advantage, click here.

This information is issued on behalf of Gateway Health Plan, Inc. d/b/a Highmark Wholecare, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 14 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 17 counties in northeastern Pennsylvania, 13 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

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

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