Prior Authorization Reminder

Reminder: Effective July 1, 2024, Highmark Wholecare providers* must submit prior authorization requests through our provider portal, GuidingCare, via NaviNet for all services requiring authorization by our Utilization Management (UM) Department. The GuidingCare User Guide is available on the Highmark Wholecare Provider Resource Center.

If the portal is unavailable, you can fax or call our UM team. The UM team can be reached by calling 1-800-392-1147 or through the fax numbers found on our provider website.

Services requiring authorization through HealthHelp should continue to be submitted through HealthHelp. Additionally, authorization requests for chemotherapeutic drugs, symptom management drugs, and supportive agents should continue to be submitted through OncoHealth.

*Shift care providers are not required to submit their prior authorization requests through the GuidingCare portal and may continue to follow their current prior authorization request process.

Prior to using a non-participating lab or providing a service that is not covered by PA Medicaid or CMS, you must request a prior authorization.

If you would like more information on the provider appeal process, please reference the Highmark Wholecare Medicaid and Medicare Provider Manuals. Thank you for your continued support in providing care to our Highmark Wholecare members.

NaviNet® is a separate company that provides an internet-based application for providers to streamline data exchanges between their offices and Highmark Wholecare such as routine eligibility, benefits and claims status inquiries.

HealthHelp is a separate company that offers education and guidance from specialists in sleep, cardiology, radiation oncology, musculoskeletal, diagnostic imaging, and physical medicine for Highmark Wholecare.