Practitioner Excellence Program

Introducing the Enhanced Provider Pay-for-Performance Program

At Highmark Wholecare, we value the important role practitioners play in serving our members. We support recognizing and rewarding performance for those practices committed to providing quality healthcare that is accessible and efficient. Therefore, working collaboratively with an advisory work group of network primary care practitioners, (MD, DO, NP, OB/GYN, and DDS) Highmark Wholecare would like to welcome you to the enhanced Practitioner Excellence Program. This program supports Highmark Wholecare’s mission to improve the health and wellness of the individuals and the communities we serve by providing access to integrated, superior health care.

2025 Program Overview

• Providers must opt-in to the program (either/both the Highmark Wholecare Practitioner Excellence (HWPE) Program and the Maternity Quality Program) to be eligible for payments.
• Providers must meet the minimum membership requirements noted in the Who Is Eligible for the Program section below.
• Each measure within the HWPE requires the entity to have a minimum of 10 members in the denominator to qualify to be scored. The measures within the Maternity Quality Program have a minimum requirement of 20 deliveries within the measure year.
• Following the completion of the 2025 HWPE Program, eligible providers will receive one payment. Payment will be made by June 30, 2026, to allow for final claims runout and data analysis.
• Payments can be earned through benchmarks and/or a percentage point improvement over the prior year’s performance. Additional percentage point improvement dollars can be earned through Health Equity Measures, for year-over-year improvement for black members within specific measures.

Who Is Eligible for the 2025 Program?

2025 Medicaid Program:

• Minimum panel size requirements are a combined membership of 500 for both Medicare and Medicaid lines of business at the entity level.
• Primary Care Physician: Family Practice, Internal Medicine, Pediatricians, Certified Registered Nurse Practitioner, Physician Assistants, Obstetrician.
• Dentists (no minimum panel size required).

2025 Medicare Program:

• Minimum panel size requirements are as follows
  – 100 Medicare members at the entity level OR 500 combined Medicare/Medicaid members at the entity level (membership is through assignment).
  – Federally Qualified Health Centers (FQHCs) are automatically eligible.
• Primary Care Physician: Family Practice, Internal Medicine, Pediatricians, Certified Registered Nurse Practitioner, Physician Assistants.

2025 Practitioner Guide

Highmark Wholecare Final Practitioner Guide

2025 Presentation

Highmark Wholecare Practitioner Excellence Presentation* 

2025 Pediatric Shift Care Incentive Program

Highmark Wholecare Pediatric Shift Care Incentive Program Guide

If you have any questions about the Practitioner Excellence pay-for-performance program, please contact your Highmark Wholecare Clinical Transformation Consultant or your Provider Account Liaison.

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