Ensuring Quality Care and Service through our QI/UM Program

The Highmark Wholecare Quality Improvement/Utilization Management (QI/UM) Program strives to ensure our members receive excellent health care and services. To help achieve this, Highmark Wholecare continuously monitors how well we’re helping our members:

• Get preventive care
• Receive care for long-standing health problems
• Understand the medicines they take
• Stay out of the hospital
• Have appropriate access to providers
• Make and keep doctor appointments
• Share health information with their doctors
• Receive care in a culturally competent manner

The Program uses results from member surveys, medical record reviews, the Healthcare Effectiveness Data Information Set (HEDIS^®), and other tools to measure how we are doing and to help set goals for future quality activities. We also work closely with you, our network providers, to monitor the care and services our members receive and determine what we can do to better serve them. Highmark Wholecare maintains a QI/UM Work Plan to analyze activities conducted as part of its QI/UM Program. This Work Plan is evaluated every three months to identify issues and ensure that actions have been taken to address them.

We also conduct an annual review of our QI/UM Program to see how well we’ve met the health care and service needs of our members. The annual evaluation of the 2024 QI/UM Program is complete, and we accomplished the majority of the Program goals, implemented new and innovative programs, identified areas for improvement, and are developing plans to address improvement opportunities in 2025. 

Please call Provider Services if you would like to request more information about our 2025 Quality Program, QI Work Plan, or summary evaluation of the 2024 QI/UM Program.

• Medicaid: 1-800-392-1147 (TTY: 711)
• Medicare: 1-800-685-5209 (TTY: 711)