Medicaid Forms Reference Materials

Medicaid Provider Manual
Provider Manual

Provider Rebranding Reference Materials
Highmark Wholecare New Branding - YouTube Video
Highmark Wholecare Rebranding FAQs for Providers

NIA Reference Material
NIA Reference Material

Medicaid Provider Forms and Reference Material
PHARMACY FORMS
Drug Exception Form
Drug Specific Prior Authorization Forms - Submit e-PA Requests via CoverMyMeds
Home Infusion Drug Request Form
Oncology and Supportive Therapy Request Form Submit requests via Navinet.
GENERAL PROVIDER FORMS & REFERENCES
After Hours Services
BetterDoctor Provider FAQ
Certification for Expedited Review Form
Clinical Services Referral Guide
CMS UB04 Form
CMS-1500 Form
Consent for Provider to File a Grievance for Member
Consent to Release Health Information to Coordinate Physical and Behavioral Health Care
Cultural Competency Data Form
Electronic Billing Companion Document
EPSDT Billing Document
FQHC RHC Billing Guide
How to Use the Provider Portal Search Tool
Language Form
Lead Screening Analysis Form
MA30 - Hysterectomy English
MA30 - Hysterectomy Spanish
MA31 - Sterilization Form - English
MA300X - Medical Assistance Provider Order Forms for Providers
Mass Claims Adjustment Coding Guide
Mass Claims Adjustment Tip Sheet
Maternity Outcome Authorization Form
Member Benefit Packages / Co-Pay Matrix
Member Outreach Form
Obstetrical Billing Guide
OB Care Enhancements Provider Training
Obstetrical Needs Assessment Form (ONAF)
Optum OB User Guide
Opioid - CDC Guideline for Prescribing Opioids for Chronic Pain
Outpatient Program Exceptions Request – Please submit via Navinet.
Pediatric Telehealth Guide
Practice/Provider Change Request Form
Prior Authorization Requirements (PA)
Provider Self-Audit Overpayments Form
Refund Form
School Vaccination Requirements
Structured Screening for Developmental Delays and Autism Spectrum Disorders
W-9 Form

This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 14 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

Medicaid Forms Reference Materials

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