Clinical Practice and Preventive Health Guidelines

Highmark Wholecare believes in providing the best possible health care to our members. To help promote excellent care, we follow clinical practice and preventive health guidelines. These guidelines are based on the latest clinical practice guidelines from professionally and industry-recognized sources or through the experience of board-certified providers from appropriate specialties when guidelines are not available. They help guide our providers in administering consistent, high-quality health care for specific conditions relevant to our members. Providers are encouraged to review these applicable guidelines. They are not meant to replace the clinical judgement of our providers, but instead to support you in making informed decisions about the best care for our members. 

Before we put these guidelines into practice, they are reviewed and approved by Highmark Wholecare’s Quality Improvement and Utilization Management Committee.

Examples of some of the guidelines include:

• Pediatric Preventive/Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)/Lead Screening (Birth to age 21)
• Adult Preventive Care
• Asthma
• Attention Deficit Hyperactivity Disorder (ADHD)
• Bipolar
• Cardiac Medical Management
• Chronic Obstructive Pulmonary Disease (COPD)
• Cystic Fibrosis
• Depression
• Diabetes
• Human Immunodeficiency Virus (HIV)
• Hypertension
• Major Depression in Adults in Primary Care
• Opioid Prescribing for Chronic Pain
• Healthy Weight Management
• Healthy Weight Management in Children and Adolescents
• Palliative Care
• Routine and High-Risk Prenatal Care
• Preventive Dental Care
• Schizophrenia
• Sickle Cell Disease
• Substance Use Disorder

A complete listing of the Medicaid and Medicare guidelines are available on our provider website. Guidelines can be printed from the website or to receive a paper copy, call Provider Services at 1-800-392-1147 (Medicaid) or 1-800-685-5209 (Medicare).