2025 Annual Provider Accessibility Audit Results

Highmark Wholecare conducted the 2025 Annual Accessibility Audit of Medicaid and Medicare D-SNP primary care providers, medical specialists, and behavioral health specialists during the second quarter of this year. The audit determined if participating practice sites were adhering to established access standards related to the timeliness of member care. Practice sites that failed one or more standards have received a letter indicating required next steps.

All around, the audit results were positive and identified the overall following achievements:

Medicaid

• Primary care practice sites see patients for routine care within 10 days, urgent care within 24 hours, and provide timely access to after-hours care.

• Ob-gyn specialist practice sites provide timely access to urgent care within 24 hours. Additionally, they showed improvement for seeing patients for routine care within 10 business days.

• Oncology specialist practice sites see patients for routine care within 10 days and urgent care within 24 hours. They also see patients within 30 minutes of their scheduled appointment for routine care and make three attempts to contact patients for missed appointments with at least one attempt by phone.

Medicare

• Primary care practice sites see patients for routine care within 30 days, urgent care within 24 hours, non-urgent but in need of medical attention care within 1 week, and provide timely access to after-hours care.

• Ob-gyn specialist practice sites provide timely access to urgent care within 24 hours and see patients within 30 minutes of their scheduled appointment for routine care.

• Oncology specialist practice sites see patients for urgent care within 24 hours and see patients within 30 minutes of their scheduled appointment for routine care.

• Behavioral health practice sites see patients for urgent care within 48 hours and non-life-threatening emergency within six hours. Additionally, they showed significant improvement for seeing patients for initial routine care within 10 days.

To promote continued improvement in access to care, Highmark Wholecare is focusing on the continuous education of our provider network through the Accessibility Standards. Please use the resources found on our provider website to supply continued education for your office staff that schedule member appointments, including central scheduling and call center staff.

The next annual accessibility audit will be launched in the second quarter of 2026.

Thank you for your participation in the audit and ensuring patients have timely access to care!