September 2025

Effective January 1, 2026: Benefit Information for Highmark Wholecare Medicare Assured D-SNP Members

Highmark will again be offering a Dual Eligible Special Needs Plan (D-SNP) in 62 Pennsylvania counties in 2026. To ensure patients receive Special Supplemental Benefits for Chronically Ill (SSBCI), providers must attest to patient eligibility through attestation forms or proper diagnosis coding

Promoting Quality

2025 Annual Provider Accessibility Audit Results

The Highmark Wholecare provider network received overall positive audit results which identified several achievements among primary care providers, medical specialists, and behavioral health specialists. With the next audit occurring in 2026, you can continue to educate your office staff on accessibility standards and improving access to care.

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Promoting quality

Medicaid CAHPS Satisfaction Scores are Here

The 2025 Medicaid of Consumer Assessment of Healthcare Providers and Systems (CAHPS) results show many improvements this year but also highlight some opportunities for growth. Continue reading to learn where scores are high and the key areas to focus on in 2026.

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Care Management

Streamline Care Gap Management with the 2025 CGMA

Tracking and resolving care gaps are made easy with the Highmark Wholecare Gap Management Application. Review your practice profile today.

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Patient Resources

Extended Day Supplies for Preferred HIV and Hepatitis Medications

Patients can save time and money with extended day supplies of their medications. They can receive up to a 90 day supply of select HIV medications and up to a 60 day supply of select Hepatitis medications.

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Important information

• Cotiviti Pre-Payment Claims Pattern Review (CPR)

• GLP-1 Maintenance Dosing: A Key to Effective Treatment

• Protecting Your Patients This Winter Season

• Important Information Regarding Tirosint® and Medicaid Coverage

• EPSDT Dyslipidemia Screening

• Upcoming Provider Webinar: Navigating Telehealth – Best Practices for Virtual Care

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

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

• 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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