Provider Resource Center

[{"id":392,"versionId":5,"title":"UM Transitions","type":4,"subType":null,"childSubType":"","date":"3/26/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003e\u003cstrong\u003eImportant UM Authorization Updates:\u003c/strong\u003e Starting May 1st, there will be updates to the authorization requirements and processes for various Highmark Wholecare services. To learn more about these specific changes and to review reference materials, visit the following links:\u003cstrong\u003e \u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/391/New-Authorization-Requirements-for-Musculoskeletal-Pain-Management-Diagnostic-Imaging-and-Physical-Medicine\"\u003eMusculoskeletal/Pain Management, Diagnostic Imaging and Physical Medicine\u003c/a\u003e,\u003c/u\u003e\u003c/strong\u003e\u0026nbsp;\u003cstrong\u003e\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/390/New-Authorization-Process-for-Family-Planning\"\u003eFamily Planning\u003c/a\u003e,\u003c/u\u003e\u0026nbsp;\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/389/New-Authorization-Requirements-for-Cardiology\"\u003eCardiology\u003c/a\u003e\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":393,"versionId":5,"title":"UM Fax Number Update","type":4,"subType":null,"childSubType":"","date":"3/26/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp style=\"margin: 0in;\"\u003eHighmark Wholecare has made updates to the Utilization Management (UM) fax numbers to help better service provider requests. The new fax numbers are specific to various Highmark Wholecare Medicare and Medicaid services and can be found \u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/378/UM-Fax-Number-Changes\"\u003e\u003cb\u003ehere\u003c/b\u003e\u003c/a\u003e\u003c/u\u003e\u003cb\u003e. \u003c/b\u003eThese new fax numbers are now live and should be used going forward. \u003co:p\u003e\u003c/o:p\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":383,"versionId":5,"title":"Change Healthcare Cyber Incident Banner","type":4,"subType":null,"childSubType":"","date":"3/19/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eImportant Provider Notice - March 5, 2024 - Change Healthcare Event: Highmark Wholecare Claims/Remittance Update\u0026nbsp;-\u0026nbsp;\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/BS_Wholecare%20Provider%20Notification%20Change%20Healthcare%20Update%20FINAL%203.5.24%20245pm.pdf\"\u003ePlease click here for more information.\u003c/a\u003e\u0026nbsp;Additionally, to learn more about how Highmark Wholecare is assisting providers impacted by the Change Healthcare cyber event, click \u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/382/Assistance-for-Highmark-Wholecare-Participating-Providers-Impacted-by-Change-Healthcare-Cyber-Event\"\u003ehere.\u003c/a\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":289,"versionId":5,"title":"E-Subscribe Provider Website Banner","type":4,"subType":null,"childSubType":"","date":"12/6/2023","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eThe Highmark Wholecare Provider Newsletter has been replaced with the \u003cstrong\u003e\u003cem\u003eProvider News\u003c/em\u003e monthly email\u003c/strong\u003e. The \u003cem\u003eProvider News\u003c/em\u003e email will become our primary communications channel, allowing us to consolidate and simplify updates for you each month. \u003ca href=\"https://wholecare.highmarkprc.com/e-Subscribe-for-Publications-and-Notifications\"\u003eSubscribe here\u003c/a\u003e to stay up-to-date with Highmark Wholecare member programs, provider policies, claims, reimbursement, and more!\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":287,"versionId":5,"title":"GuidingCare Provider Website Banner","type":4,"subType":null,"childSubType":"","date":"11/30/2023","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp style=\"margin: 0in;\"\u003eProviders now have access to a new Clinical Platform, GuidingCare. This platform allows access to an Authorization Portal via NaviNet. Please utilize this online capability as the preferred method to submit your authorization requests. To learn more about accessing this new platform, please review the provider guide \u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/docs/GuidingCareUserGuide.pdf\"\u003ehere\u003c/a\u003e.\u003co:p\u003e\u003c/o:p\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2}]

Overview

Our Health Plan maintains accessibility to care standards and processes for ongoing monitoring of access to health care. Providers are contractually required to conform to the Accessibility to Care standards to ensure that health care services are provided to Highmark Wholecare members in a timely manner.

[{"id":4,"versionId":34,"chapterNumber":1,"title":"Accessibility Standards","visible":false,"topics":[{"id":14,"chapterId":4,"unitNumber":1,"timestamp":"1/1/0001","title":"Accessibility Standards","description":"\u003cp\u003eHighmark Wholecare\u0026rsquo;s Medicaid and Medicare Accessibility Standards:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/Appointment_AfterHoursStandards.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eAccessibility Standards\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/BehavioralHealthAccessStandardsDetail.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eBehavioral Health Accessibility Detail\u003c/a\u003e\u003c/li\u003e\n\u003c/ul\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":6,"versionId":34,"chapterNumber":2,"title":"Monitoring Compliance with Accessibility Standards","visible":false,"topics":[{"id":37,"chapterId":6,"unitNumber":2,"timestamp":"1/1/0001","title":"Monitoring Compliance with Accessibility Standards","description":"\u003cp\u003eHighmark Wholecare has contracted with Press Ganey, a National Committee for Quality Assurance (NCQA) certified vendor to conduct annual audits to assess our provider network\u0026rsquo;s ability to provide Highmark Wholecare members with timely access to care.\u003cbr /\u003eThe audit addresses:\u003cbr /\u003e■ Appointment availability based on Highmark Wholecare standards\u003cbr /\u003e■ Access to care 24 hours a day/7 days a week\u003cbr /\u003e■ Wait time in the waiting room\u003cbr /\u003e■ Missed appointment protocol\u003c/p\u003e\n\u003cp\u003eThe audit results are utilized to identify plan strengths and barriers to care, and provides Highmark Wholecare with the opportunity to develop initiatives to improve access.\u003c/p\u003e\n\u003ch3\u003eACCESSIBILITY AUDIT\u003c/h3\u003e\n\u003cp\u003eThe Accessibility audit is conducted annually, typically in the\u0026nbsp;2nd Quarter of the year.\u003cbr /\u003e■ Press Ganey will contact a random sample of our provider network by phone to complete the audit. Call-center agents will ask series of questions to determine compliance with Highmark Wholecare Accessibility Standards.\u003cbr /\u003e■ The call-center agent will request that the office appointment schedule be reviewed (real-time) to obtain a specific date and time of the office\u0026rsquo;s next available appointment.\u003cbr /\u003e■ Identification of office protocol or instructions provided to members by provider offices may also be included as part of the audit.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eIMPORTANT AUDIT INFORMATION\u003c/h3\u003e\n\u003cp\u003e■ Providers are contractually obligated to participate in the audit.\u003cbr /\u003e■ Highmark Wholecare will announce the upcoming annual audit via fax blast and provider newsletter\u003cbr /\u003e■ Scheduling staff should be educated on the standards and aware of the audit time frame\u003cbr /\u003e■ The audit is conducted telephonically and will take 5 minutes to complete\u003cbr /\u003e■ Provider offices that are non-compliant with one or more standards will receive a report card identifying each non-compliant standard along with required actions\u003cbr /\u003e\u003cbr /\u003e\u003c/p\u003e\n\u003ch3\u003eWHAT YOU CAN DO TO PREPARE FOR THE AUDIT\u003c/h3\u003e\n\u003cp\u003e■ Key office staff that schedule member appointments should review\u003cspan\u003e\u0026nbsp;\u003c/span\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/Appointment_AfterHoursStandards.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eHighmark Wholecare\u0026rsquo;s Practitioner Accessibility Standards.\u003c/a\u003e\u003cbr /\u003e\u003cstrong\u003eImportant:\u003c/strong\u003e\u003cspan\u003e\u0026nbsp;\u003c/span\u003eEducation of staff responding to the accessibility audit questions is a contributing factor to compliance with the standards.\u003cbr /\u003e■ Complete a Practice Self-Assessment to determine if your practice meets Highmark Wholecare\u0026rsquo;s Access to Care Standards.\u003cbr /\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/PracticeSelfAssessmentTool.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003e\u003cstrong\u003ePractice Self-Assessment Tool\u003c/strong\u003e\u003c/a\u003e: The tool contains the accessibility standards monitored by Highmark Wholecare for both Medicaid and Medicare, the criteria a practice must meet to be compliant with the standards, and identifies questions that may be asked by call-center agents during an Accessibility Audit.\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":16,"versionId":34,"chapterNumber":3,"title":"Annual Provider Accessibility Audit Process","visible":false,"topics":[{"id":45,"chapterId":16,"unitNumber":3,"timestamp":"1/1/0001","title":"Annual Provider Accessibility Audit Process","description":"\u003cp\u003e\u003cspan\u003eHighmark Wholecare\u0026rsquo;s Annual Provider Accessibility Audit Process:\u003c/span\u003e\u003cbr /\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/AuditProcess.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eAnnual Provider Accessibility Audit Process\u003c/a\u003e\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":12,"versionId":34,"chapterNumber":4,"title":"Provider Non-Compliance with Standards","visible":false,"topics":[{"id":41,"chapterId":12,"unitNumber":4,"timestamp":"1/1/0001","title":"Provider Non-Compliance with Standards","description":"\u003cdiv class=\"collapseArea opened\" id=\"col5\" role=\"region\" aria-labelledby=\"accHeading5\"\u003e\n\u003cp\u003eProvider offices that are non-compliant with one or more standards will receive a report card identifying each non-compliant standard along with required actions to mitigate non-compliance.\u003cbr /\u003e\u003cstrong\u003eNon-compliant: One (1) year\u003c/strong\u003e\u003cspan\u003e\u0026nbsp;\u003c/span\u003eProviders that are non-compliant with 1 or more standards based on the results of the annual audit will be:\u003cbr /\u003e1. Required to submit an action plan within 45 days\u003cbr /\u003e2. Required to complete staff training within 45 days\u003cbr /\u003e3. Required to complete a practice self-assessment of compliance within 45 days\u003cbr /\u003e4. Required to attest to the completion of staff training and practice self-assessment within 45 days\u003cbr /\u003eNote: Your completion of the provider access corrective action plan online submission form on the provider website will satisfy all actions listed above.\u003cbr /\u003e5. Resurveyed in the following years annual audit\u003cbr /\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/NonCompliant1yrAuditResultsNotification.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eExample of Audit Results Notification Noncompliant 1 Year\u003c/a\u003e\u003cbr /\u003e\u003cbr /\u003e\u003cstrong\u003eNon-Compliant: Two (2) consecutive years\u003c/strong\u003e\u003cbr /\u003eProviders that are non-compliant with 1 or more standards for two consecutive years based on the results of the annual audit and the previous year annual audit will be:\u003cbr /\u003e1. Required to submit an action plan within 45 days\u003cbr /\u003e2. Required to complete staff training within 45 days\u003cbr /\u003e3. Required to complete a practice self-assessment of compliance within 45 days\u003cbr /\u003e4. Required to attest to the completion of staff training and practice self-assessment within 45 days\u003cbr /\u003eNote: Your completion of the provider access corrective action plan online submission form on the provider website will satisfy all actions listed above.\u003cbr /\u003e5. Additional actions may be required.\u003cbr /\u003e6. Resurveyed in the following years annual audit\u003cbr /\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/NonCompliant2yrAuditResultsNotification.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003e\u0026ldquo;Example of Audit Results Notification Non-compliant 2 Year\u0026rdquo;\u003c/a\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"ghpAccordion\"\u003e\n\u003ch3 class=\"accHeading\" role=\"heading\" id=\"mcetoc_1hqvfp9lu0\"\u003e\u003c/h3\u003e\n\u003c/div\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":13,"versionId":34,"chapterNumber":5,"title":"Accessibility Compliance Tips","visible":false,"topics":[{"id":42,"chapterId":13,"unitNumber":5,"timestamp":"1/1/0001","title":"Accessibility Compliance Tips","description":"\u003cp\u003e\u003cspan\u003e■ Ensure that you have coverage for vacation or an extended absence by another practitioner or you can refer members to another practice or telemedicine provider. Refer to the Medicaid and Medicare Provider Manuals on our provider website for more information regarding telemedicine.\u003cbr /\u003e\u003c/span\u003e\u003cbr /\u003e\u003cspan\u003e■ Share the accessibility standards, Audit questions, and Audit process with key staff that schedule appointments, including central scheduling/call centers. Education of staff responding to the audit questions is a contributing factor to compliance with the standards.\u003c/span\u003e\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":14,"versionId":34,"chapterNumber":6,"title":"Practice Self Assessment Tool","visible":false,"topics":[{"id":43,"chapterId":14,"unitNumber":6,"timestamp":"1/1/0001","title":"Practice Self Assessment Tool","description":"\u003cp\u003e\u003cspan\u003eHighmark Wholecare\u0026rsquo;s Practice Self-Assessment Tool:\u003c/span\u003e\u003cbr /\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/PracticeSelfAssessmentTool.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003ePractice Self-Assessment Tool\u003c/a\u003e\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":15,"versionId":34,"chapterNumber":7,"title":"Frequently Asked Questions (FAQs)","visible":false,"topics":[{"id":44,"chapterId":15,"unitNumber":7,"timestamp":"1/1/0001","title":"Frequently Asked Questions (FAQs)","description":"\u003cp\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/AccessFAQ.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eFrequently Asked Questions (FAQs)\u003c/a\u003e\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":21,"versionId":34,"chapterNumber":8,"title":"PROVIDER ACCESS CORRECTIVE ACTION PLAN (CAP) -ONLINE SUBMISSION FORM","visible":false,"topics":[{"id":50,"chapterId":21,"unitNumber":0,"timestamp":"1/1/0001","title":"Corrective Action Plan (CAP)","description":"\u003cp\u003eThank you for choosing to complete your Provider Access Corrective Action Plan (CAP) online. Your practice site should have received a Provider Report Card. This Report Card outlines your Provider Access Audit Results and what standards your site has failed that require a CAP. Please follow the below steps to complete the CAP form.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Click\u0026nbsp;\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/CAPSubmissionFormInfo.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003ehere\u003c/a\u003e to see what is needed to complete the online submission form.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Click \u003ca href=\"https://wholecare.highmarkprc.com/Provider-Resources/CAP-Form\"\u003ehere\u003c/a\u003e to complete the CAP form.\u003c/p\u003e","filename":"","visible":false,"liveStatus":2}],"liveStatus":2},{"id":22,"versionId":34,"chapterNumber":9,"title":"Behavioral Health Educational Tools","visible":false,"topics":[{"id":51,"chapterId":22,"unitNumber":0,"timestamp":"1/1/0001","title":"Behavioral Health Educational Tools","description":"\u003cp\u003e\u003ca href=\"https://youtu.be/iR1ePDyt-4M\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eBehavioral Health Provider Access Education Recording\u003c/a\u003e\u0026nbsp;- YouTube Video\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/docs/BH_ProviderAccessEd.pdf\"\u003eBehavioral Health Provider Access Education\u003c/a\u003e\u0026nbsp;- PDF\u003c/p\u003e","filename":"https://youtu.be/iR1ePDyt-4M","visible":false,"liveStatus":2}],"liveStatus":2}]

Revision Date

Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.

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