In order for providers to participate with the Department of Human Services, they must first enroll. To be eligible to enroll, practitioners in Pennsylvania must be licensed and currently registered by the appropriate state agency. Out-of-state practitioners must be licensed and currently registered by the appropriate agency in their state and they must provide documentation that they participate in that state’s Medicaid and/or CHIP program. Other providers must be approved, licensed, issued a permit, certified by the appropriate state agency, or if applicable certified under Medicare.
To enroll, providers can complete an on-line provider enrollment application and supply any required supporting documentation. This includes providers who are not billing PA Medicaid or CHIP but provide services to beneficiaries. All applications will be screened based on Federal and State guidelines prior to an enrollment decision. Please retain copies of your application materials for your records. You will receive a response upon approval or denial of your enrollment with PA Medicaid and/or CHIP.
Types of Provider Enrollment Applications
There are three types of enrollment applications and each requires a provider to complete an entire application. Please click the appropriate navigation item on the left hand side of the page to start a “New Application”, “Revalidation” or “Reactivation”.
Provider Application Fee
The Affordable Care Act requires states to collect an application fee, if applicable, prior to executing a provider agreement from a prospective or re-enrolling provider. Refer to 42 CFR 455, Subpart E – Provider Screening and Enrollment, Section 455.460 for the complete regulation. The Centers for Medicare & Medicaid Services (CMS) sets the amount of the application fee every year.
Providers may request a hardship exception to the application fee requirement. If an exception is requested, the provider will be prompted to submit (upload) documentation. CMS will determine whether or not to grant the hardship exception and communicate the information back to the department. The department will notify the provider of the CMS’ decision.
To pay an application fee, providers must enroll and revalidate through the Electronic Provider Enrollment Application.
The department will assess and collect one fee for multiple applications submitted by one provider in a 7 day time period. Providers who wish to submit multiple applications (for multiple service locations) and pay one fee should use the "Initiate Additional Application" feature and submit all applications within 7 days.
For more information about the application fee, please see the ACA Enrollment Application Fee Medical Assistance Bulletin. For CHIP providers, please contact your designated CHIP Managed Care Organization(s).
Fingerprint-based Criminal Background Checks
Providers assigned to the "high" categorical risk level are required by the Affordable Care Act to obtain fingerprint-based criminal background checks, which include a Federal Bureau of Investigation (FBI) criminal background check and a Pennsylvania State Police Criminal Record Check. In addition, any person with a 5% or more direct or indirect ownership interest in the "high" risk provider must also submit fingerprint-based background checks. Refer to 42 CFR 455, Subpart E – Provider Screening and Enrollment, Section 455.434 for detail on the regulation.
For more information about the Fingerprint-based Criminal Background Checks and criteria used to assign a provider to the "high" categorical risk level, please see the Implementation of Fingerprint-based Criminal Background Checks for Providers Assigned ACA Categorical Risk Level of High Medical Assistance Bulletin. For CHIP providers, please contact your designated CHIP Managed Care Organization(s).
Tracking Provider Enrollment Applications
A unique number called the "Application Tracking Number" (ATN) will be assigned when a "New Application", "Revalidation" or "Reactivation" is started. Prior to exiting the application, write down this number and keep it for your records. If you need to access the application later, please click the appropriate navigation item on the left hand side of the page to "Resume Application" or to check the "Application Status". Note: Information will not be retained and the application will be deleted if the provider does not complete the application, supply the required supporting documentation and click the "Submit Application" button on the "Summary" page when finished.
The following menu bar options will open a web page in a new browser window so information can be viewed while continuing with the application. Please click the appropriate heading at the top of the page to obtain additional information.
At a minimum this site requires Microsoft Internet Explorer version 11 with 256 bit encryption. All enrollment attachments must be uploaded in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view certain supporting documents.