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Published Date: 2025-07-22

Provider Appeal Form Now Available for Fax and Mail Submissions

Highmark Wholecare values our providers and the high-quality, complete care you deliver to our members. To help simplify the appeals submission process and make reviews more efficient, we have created the Highmark Wholecare Provider Appeal Form, which must be included with any post-service appeal submitted by fax or mail. When you submit a post-service appeal through the NaviNet Provider Portal, you will be prompted to complete this form within the portal.

Please note, this form is only for post-service appeals, including reconsiderations of claim denials, retrospective reviews, and denied services. This form should not be used for member appeals, pre-service appeals, payment disputes, or resubmissions of corrected claims, which must be submitted to the Member Appeals Department or Claims Department, respectively.

As a reminder, if you disagree with a denial and wish to formally dispute the decision, you have several options for submitting a post-service appeal:

NaviNet Provider Portal (preferred method)
Fax: 1-855-501-3904
Mail: Highmark Wholecare, Attn: Provider Appeals, P.O. Box 22278, Pittsburgh, PA 15222

To ensure timely processing and review, your appeal request must include:

A Provider Appeal Form. All sections of the form must be completed.
A written explanation of the appeal. Ensure you clearly state the reason for the appeal.
Claim Number(s) being appealed.
Date of service being appealed.
Code(s) being appealed.
Complete and relevant supporting clinical documentation.
Return mailing address. Provide a complete and accurate address for the appeal decision letter.
Timely filing limits apply.

If any of the above information is missing, this may result in the appeal being denied. If you have any questions about this form or the appeals process, please contact Provider Services at 1-800-685-5209 (Medicare) or 1-800-392-1147 (Medicaid).

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.