Welcome to Highmark Wholecare
We're so glad you decided to join the family. As members, you have access to a wide variety of tools and resources designed to keep you and your family healthy.
When you have a question about your Medicaid benefits through Highmark Wholecare, look in the latest Member Handbook. Members can request a printed copy of the Member Handbook by calling Member Services at 1-800-392-1147 (TTY:711 or 1-800-654-5984), Monday–Friday, 8 a.m.–8 p.m.
Cuando tenga una pregunta sobre sus beneficios de Medicaid a través de Highmark Wholecare, consulte el Manual para miembros más reciente. Los miembros pueden solicitar una copia impresa del Manual para miembros llamando a Servicios para miembros al 1-800-392-1147 (TTY: 711 or 1-800-654-5984), de lunes a viernes, de 8 a.m.–8 p.m.
Getting Started
- You will receive a letter in the mail from Highmark Wholecare that tells you who we are and how we can help you. This letter also includes access to your Member Handbook, which will help answer many questions you may have.
- You will receive your Highmark Wholecare member ID card in the mail. Make sure the PCP listed on your ID card is the one you want. Call Member Services right away if the PCP on your ID card is not the PCP you want. Check other information on the ID card to make sure it is right, too. Call the phone number on the back of your ID card when you need help or information. Remember: Always keep your Highmark Wholecare member ID card and Pennsylvania Medicaid card with you. Show both cards every time you need health care services. Do not let anyone else use your Highmark Wholecare member ID card.
If you provided your phone number during enrollment, a representative from Member Services will call you to welcome you to Highmark Wholecare.
You can always call Member Services at 1-800-392-1147 (TTY: 711), Monday–Friday, 8 a.m.–8 p.m. to get your questions answered. Call the 24-Hour Nurse Line at 1-800-392-1147 if you have a question about a health concern or need advice about where to go for care (primary care, urgent care, or emergency care).
Your Next Steps
If you haven't already done so, follow these simple steps.
- Sign up for the Member Portal to manage your benefits, primary care physician and transportation service benefits
- Choose a Provider
- Discover how Care Transitions can help
- Check out our Member Newsletters
- Learn about the Recipient Restriction Program
- Visit the Medication Information Center
- Search for a drug with our Medicaid Drug Search
- Review Grievances and Appeals
- Review the Member Rights and Responsibilities at the bottom of this page
Televisit Consent Forms
Review Member Rights and Responsibilities
Member Rights
As a Highmark Wholecare member, you have the right to:
- Be treated with respect, recognizing your dignity and need for privacy, by Highmark Wholecare staff and network providers.
- Get information in a way that you can easily understand and find help when you need it.
- Get information that you can easily understand about Highmark Wholecare, its services and the doctors and other providers that treat you.
- Pick the network health care providers that you want to treat you.
- Get emergency services when you need them from any provider without Highmark Wholecare’s approval.
- Get information that you can easily understand and talk to your providers about your treatment options, risks of treatment and tests that may be self-administered without any interference from Highmark Wholecare.
- Make all decisions about your health care, including the right to refuse treatment. If you cannot make treatment decisions by yourself, you have the right to have someone else help you make decisions or make decisions for you.
- Talk with providers in confidence and to have your health care information and records kept confidential.
- See and get a copy of your medical records and to ask for changes or corrections to your records.
- Ask for a second opinion.
- File a Grievance if you disagree with Highmark Wholecare’s decision that a service is not medically necessary for you.
- File a Complaint if you are unhappy about the care or treatment you have received.
- Ask for a DHS Fair Hearing.
- Be free from any form of restraint or seclusion used to force you to do something, to discipline you, to make it easier for the provider, or to punish you.
- Get information about services that Highmark Wholecare or a provider does not cover because of moral or religious objections and about how to get those services.
- Exercise your rights without it negatively affecting the way DHS, Highmark Wholecare, and network providers treat you.
- Create an advance directive. See Section 6 on page 70 of the Member Handbook for more information.
- Make recommendations about the rights and responsibilities of Highmark Wholecare’s members.
Member Responsibilities
Members need to work with their health care service providers. Highmark Wholecare needs your help so that you get the services and supports you need.
These are the things you should do:
- Provide, to the extent you can, information needed by your providers.
- Follow instructions and guidelines given by your providers.
- Be involved in decisions about your health care and treatment.
- Work with your providers to create and carry out your treatment plans.
- Tell your providers what you want and need.
- Learn about Highmark Wholecare coverage, including all covered and non-covered benefits and limits.
- Use only network providers unless Highmark Wholecare approves an out-of-network provider or you have Medicare.
- Get a referral from your PCP to see certain specialists.
- Respect other patients, provider staff, and provider workers.
- Make a good-faith effort to pay your co-payments.
- Report fraud and abuse to the DHS Fraud and Abuse Reporting Hotline.
