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.
Effective 1/20/2023, National Imaging Associates, Inc. is now a subsidiary of Evolent Health. Evolent Health and its affiliates and subsidiaries collectively referred to as “Evolent.”
- Frequently Asked Questions
- Utilization Review Matrix-2023
- Medical Specialty Solutions Education Training PPT
- QRG for Ordering and Rendering Physicians
- Peer-to-Peer Process
- Cardiac Frequently Asked Questions
For access to our Advanced Imaging Program tip sheets/checklists, click here.
For access to our Cardiac Program tip sheets/checklists, click here.
- Physical Medicine Frequently Asked Questions
- Physical Medicine Quick Reference Guide
- Physical Medicine Education Training PowerPoint
- Physical Medicine Utilization Review Matrix-2023
For access to our Physical Medicine Program tip sheets/checklists, click here.
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-2023
- Hip, Knee and Shoulder Utilization Review Matrix-2023
- IPM Utilization Review Matrix-2023
For access to our Surgery Program tip sheets/checklists, click here.
For access to our IPM Program tip sheets/checklists, click here.
Conservative Treatment Forms
For access to our conservative treatment forms, click here.
Low Dose Chest CT History Form
RadMD is a user-friendly, real-time tool offered by NIA 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 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).