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Balance Billing Reminder

Published Date: 2024-12-17

According to our Fraud, Waste, and Abuse (FWA) section of the Medicaid and Medicare Provider Manuals and as required by the Pennsylvania Department of Human Service (DHS) Medical Assistance Bulletin 99-99-06, Payment in Full, Highmark Wholecare would like to remind providers that seeking or requesting supplemental or additional payments from recipients for covered services is legally prohibited.

The Pennsylvania Code, 55 Pa. Code § 1101.63 (a) indicates the following:

All payments made to providers under the MA program plus any copayment required to be paid by a recipient shall constitute full reimbursement to the provider for covered services rendered.
A provider who seeks or accepts supplementary payment of another kind from DHS, the recipient, or another person for a compensable service or item is required to return the supplementary payment.

If you suspect FWA, it is your responsibility to immediately notify Highmark Wholecare by calling the FWA Hotline at 1-844-718-6400. Anyone who reports FWA has the option to remain anonymous.