November 2025

Medicaid Prior Authorization List (PAL) Updates

The Highmark Wholecare Medicaid Prior Authorization List includes added procedure codes that require prior authorization beginning December 1, 2025. To view these codes, visit the Highmark Wholecare PRC.

Care Management

Prioritizing Men’s Mental Health this “Movember”

This “Movember” serves as an important reminder of the urgent need for addressing men’s mental health and well-being. Highmark Wholecare provides useful resources you can use to encourage happy and healthy lives in men’s lives.

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Process Update

Provider Overpayment Submissions and TRENDSubmit

Understanding key overpayment notifications and return rules can help you stay in compliance with federal and state regulations. Electronically submit overpayments via TRENDSubmit, a user-friendly and web-based process.

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Process Update

Timely Filing for EPSDT Claims

Due to PA DHS requirements, timely filing for EPSDT claims will change on January 1, 2026. Ensure claims are received within 90 days of the date of service to be considered timely.

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Care Management

Screening and Billing for Adolescent Depression

Early depression screening in adolescents can change lives and foster better well-being among patients. Learn why proper screening and billing practices are key to improving outcomes and supporting sustainable mental health care.

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Important information

2026 EVV Compliance Enforcement for Home Health Providers

Model of Care Training Summary

Fall Risks

Oxygen Equipment Requirements

Directory Changes

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

• 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, click here. For 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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