Highmark Wholecare (Gateway Health & Gateway Health Medicare Assured)
Welcome to the Highmark Wholecare (Gateway Health & Gateway Health Medicare Assured) Health Plan page. Here you can download policies and procedures specific to both ordering and rendering providers. These include quick reference guides and information designed to assist you in using RadMD to request and check the status of prior authorizations.
If you have any questions about our programs, please contact your dedicated NIA Provider Relations Manager:
Due to a recent Kentucky Department for Medicaid Services announcement, services performed/billed from a place of service 22 facility do not require prior authorization. This only impacts services for Kentucky Medicaid recipients. Please refer to the state website, as this is subject to change based upon additional state-issued COVID directives.
- Utilization Review Matrix-2022
- Medical Specialty Solutions Education Training PPT
- QRG for Ordering and Rendering Physicians
- Submit Radiology Authorizations Electronically
- Tip Sheet
- Peer-to-Peer Process
- Cardiac Checklist
- Cardiac FAQ
- Cardiac Solutions Tip Sheet
- NOW LIVE - Update to RadMD (New)
- Date Extension Announcement for Physical Medicine Providers
- Physical Medicine Frequently Asked Questions
- Physical Medicine Quick Reference Guide
- Physical Medicine Education Training PowerPoint
- Physical Medicine Tip Sheet/Checklist
- Physical Medicine Utilization Review Matrix-2022
Musculoskeletal (MSK)/Interventional Pain Management (IPM)
- Frequently Asked Questions - MSK/IPM
- Quick Reference Guide - MSK/IPM
- Provider Education Training - MSK/IPM
- Spine Surgery Utilization Review Matrix-2022
- Hip, Knee and Shoulder Utilization Review Matrix-2022
- IPM Utilization Review Matrix-2022
- Spine Surgery Authorization Coding Reference Guide
- Hip, Knee and Shoulder Surgery Authorization Coding Reference Guide
- Spine Surgery Checklist
- Hip, Knee and Shoulder Surgery Checklist
- IPM Checklist
- Hip and Knee Arthroplasty (Medicare) Clinical Tip Sheet
- Knee Arthroscopy Clinical Tip Sheet
- Shoulder Arthroplasty Clinical Tip Sheet
- Shoulder Arthroscopy Clinical Tip Sheet
Conservative Treatment Forms
For access to our conservative treatment forms, click here.
RadMD is a user-friendly, real-time tool offered by Magellan Healthcare that provides ordering and rendering providers with instant access to prior authorization requests for specialty procedures. Whether submitting exam requests or checking the status of prior authorization requests, providers will find RadMD to be an efficient, easy-to-navigate resource.
Search for resources by program:
Recorded General Trainings
We have a series of training videos that discuss the components of requesting a prior authorization request. Click here to access these videos.
Recorded RadMD Demos
Need additional help using RadMD? Click here to access a series of RadMD demos that demonstrate how to properly submit a prior authorization request.
- Clinical Guidelines
- Physical Medicine Guidelines (PDF 851K)
Refer to the Utilization Review Matrix document to view specific codes managed by NIA
Click here to view NIA’s Physical Medicine guidelinesMagellan adopted the use of MCG Guidelines® for its Physical Medicine product. View instructions for accessing MCG Guidelines®.
Clinical Training Modules
We have a series of clinical training modules that will help you avoid delays and ensure that you have the right information before submitting your prior authorization request. Click here to access them.
Update on COVID-19
Click here to view our recommendations on the use of CT to detect Coronavirus (COVID-19).