January 2026

GLP-1 Agonist Changes

Continue to stay in compliance by reviewing the recent bulletin from Pennsylvania’s Department of Human Services, regarding coverage and benefit changes for glucagon-like peptide-1 (GLP-1) receptor agonists for the treatment of overweight and obesity for Medical Assistance beneficiaries.

Patient Resources

Member Outreach Navigators

Providers can request support from Member Outreach Navigators, who can assist Highmark Wholecare patients with additional education and explanations of various aspects of care. By completing a Member Outreach Form, you can refer members to this resource for more support.

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Promoting Quality

Physician Portfolio Reports

The January Physician Portfolio Report is now available for access on Navinet. Access the report to learn more about specific areas where we can work together to optimize patient care and outcomes.

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Care Management

Boost CAHPS Scores

Learn more on how to elevate your practice's CAHPS scores and enhance patient health through key strategies focused on access to care, empathetic communication, and proactive health measures.

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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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Important information

2026 EVV Compliance Enforcement for Home Health Providers

Policy Updates

Annual HEDIS Medical Record Review

Post-Acute Care Management: Authorization Process Changing

Medicaid OB providers and PCPs who Provide Maternity Care

Help your Patients through the Medicaid Renewal Process

Model of 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

• Accessibility Standards

• Notice of Practice/Practitioner Changes

• Cultural Competency

• Encounters Submission

• 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, 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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