Update: Provider Portal and Prior Authorization

Prior Authorization Code Lookup Tool Now Available on the Public Website

Highmark Wholecare has created an updated Prior Authorization List (PAL) lookup to make it easier to find guidance on authorization requirements for our Pennsylvania members. You can access the tool from the Provider Resources page of our website.

Providers will be able to enter the Current Procedural Terminology (CPT) into the PAL tool to verify if there are any prior authorization requirements. The PAL will populate both Medicaid and Medicare D-SNP authorization requirements, if applicable. This tool replaces the PAL tool in the Provider Portal.

Provider Portal

Highmark Wholecare utilizes NaviNet as our provider portal. You can use NaviNet to verify member eligibility and benefits information, conduct claims search inquiries, connect to the appropriate prior authorization portals, and more.

As a reminder, there are different authorization portals that must be used for different prior authorization requests, depending on the procedure or service.

GuidingCare Authorization Portal

Any services requiring authorization from the Highmark Wholecare Utilization Management Department must be submitted electronically through GuidingCare, via NaviNet. Please reference the GuidingCare User Guide to learn about the portal’s member search functionality, member eligibility, authorization requests, and more.

HealthHelp Authorization Portal

Prior authorization requests for the following services are managed through HealthHelp:

• Musculoskeletal: Spine, knee, hip surgeries
• Pain Management
• Advanced Imaging: CT scans, PET scans, MRIs, etc.
• Physical Therapy/Speech Therapy/Occupational Therapy
• Cardiology (now includes members under the age of 18)
• Sleep Studies
• Radiation Oncology

To request prior authorizations and check status in HealthHelp, follow the instructions for HealthHelp: Single Sign-On Capabilities through NaviNet. Additionally, HealthHelp offers training webinars to assist our providers.

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, physical medicine, diagnostic imaging, and musculoskeletal and interventional pain management for Highmark Wholecare.