Medicare Assured Forms and Reference Materials



Medicare Assured 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

Medicare Assured Provider Forms and Reference Material
PHARMACY FORMS
CMS Standardized Part D Hospice Information Drug Request Form
Home Infusion Drug Request Form
Medicare Drug Exception Form
Oncology and Supportive Therapy Request Form   Submit requests via Navinet.
BEHAVIORAL HEALTH AUTHORIZATION REQUEST FORMS
Discharge Form
Inpatient Authorization Request Form
Inpatient Substance Use Authorization Request Form
Outpatient Authorization Request Form
GENERAL PROVIDER FORMS & REFERENCES
2022 Highmark Wholecare Benefits
After Hours Services
Appointment of Representative Form
Annual Wellness Visit Tools and Reference Materials
Care for Older Adults (COA) Form
Cataract Removal Questionnaire
Clinical Services Referral Guide
CMS-1500 Form
CMS UB-04 Form
Consent to Release Health Information to Coordinate Physical and Behavioral Health Care
Cultural Competency Data Form
Electronic Funds Transfer (EFT) Authorization Agreement Form
How to Use the Provider Portal Search Tool
ICD-10 Submitter-Provider Quick Start Guide
In-Service Materials
Language Form
Late Notification FAQ - Medicare
Living Will Declaration
Mass Claims Adjustment Coding Guide
Mass Claims Adjustment Tip Sheet
Maternity Outcomes Authorization Form
Medicare Outpatient Observation Attestation
Medicare Outpatient Observation Notice
Medicare Outpatient Observation Notice Instructions
Member Outreach Form
Model of Care
Non-Participating Provider Complaint Form
Obstetrical Needs Assessment Form (ONAF)
Opioid - CDC Guideline for Prescribing Opioids for Chronic Pain
Optum OB User Guide
Outpatient Program Exceptions Request – Please submit via Navinet.
Practice/Provider Change Request Form
Prior Authorization Requirements (PA)
Provider Self-Audit Overpayments Form
Refund Form
Waiver of Liability Statement Form
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 27 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.

Copyright 2022 by Highmark WholecareSM