Prior Authorization and Medical Policy Updates

Please be sure to regularly check our Highmark Wholecare Provider Resource Center (PRC) for a list of procedure codes added to the Highmark Wholecare Medicaid and Medicare Prior Authorization List (PAL) that require prior authorization.

To find these codes, visit the PRC and click on the “Resource Centers” tab. Then, under “Medicaid Resources” scroll down to Provider Updates.

You may also search CPT codes in the Main Search Bar at the top of any page on the PRC to check prior authorization requirements.

Additionally, Highmark Wholecare regularly reviews and updates our policies and procedures. To help you know when policies have been amended, an advanced notification will be provided via our newsletter or fax and posted on our website 60 days prior to the effective date. You can find the medical policy updates at the following links:

Medicaid Medical Policy Updates

Medicare Medical Policy Updates

Medicaid and Medicare Reimbursement Policy Updates

Policy Updates Effective Oct. 1, 2026

Medicaid (Reimbursement)

Annual Review:

• HWC-PA-RP-001 Maximum Units of Service-Medicaid Outpatient and Professional
• HWC-PA-RP-004 Scanning Ophthalmic Diagnostic Imaging
• HWC-PA-RP-005 ICD-10
• HWC-PA-RP-006 Preventive and Sick Visits on Same Day
• HWC-PA-RP-007 Use of NCD and LCD
• HWC-PA-RP-009 National Drug Codes (NDC)
• HWC-PA-RP-010 Telehealth
• HWC-PA-RP-011 SBIRT

New Policies:

• HWC-PA-RP-021 Physician Office Lab Testing
• HWC-PA-RP-2022 Lab Panel Testing
• HWC-PA-RP-2023 Preventive Medicine and Office/Outpatient Evaluation and Management Services
• HWC-PA-RP-2204 Critical Care with Home Discharge
• HWC-PA-RP-025 DME

Medicaid (Medical)

Annual Review:

• MP-063-MD-PA Genetic Testing for Warfarin and Clopidogrel

New Policies:

• MP-147-MD-PA Enteral Nutrition
• MP-155-MD-PA Face and Ear Prosthesis

Retired:

• MP-057-MD-PA Cardiac Rehab
• MP-091-MD-PA Deep Brain Stimulation
• MP-109-MD-PA Bronchial Valves

Medicare (Reimbursement)

Annual Review:

• HWC-PA-RP-002 Maximum Units of Service-Medicare Outpatient and Professional
• HWC-PA-RP-012 Diabetic Retinal Eye Examinations
• HWC-PA-RP-020 Opioid Treatment Providers (OTP)

Archived:

• HWC-PA-RP-003