Provider Enrollment Information

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 program.
• Other providers must be approved, licensed, issued a permit, or certified by the appropriate state agency, and — if applicable — certified under Medicare.

Online Provider Enrollment Application

Use the Online Provider Enrollment portal to submit a new application, for revalidation, or for reactivation.

Benefits of using the secure online portal:

• Allowing documents to be uploaded directly to the portal
• Permitting providers see the status of their submission
• Decreasing wait time to review applications

Co-locating or sharing space

Providers seeking to enroll at a site that is located within another provider's office may complete the attestation form and submit it and proposed signage to the department. Please follow the directions specified in the MA Bulletin 99-16-04. The attestation forms are attached to the MA Bulletin.

Criminal Background Check

The Department of Human Services has assigned certain provider types and specialties to the "high" categorical risk level. The Affordable Care Act (ACA) requires all providers deemed to be a high categorical risk level to obtain criminal background checks, which include a Federal Bureau of Investigation (FBI) criminal background check and a Pennsylvania State Police Criminal Record Check. Any person with a 5 percent or greater direct or indirect ownership interest in the high-risk provider must also submit criminal background check information. For more information, please see Medical Assistance Bulletin 99-17-03 or visit the OMAP section of the Provider Clearances and Background Checks page.

Additional Enrollment Forms

Use the PROMISe™ Service Location Change Request and Instructions If you need help with the following:

• I need to close a service location on my provider file - Refer to PART 1
• I need to change the mailing, payment and/or 1099 address for an existing service location on my provider file - Refer to PART 2
  
• I need to terminate an assignment of fees - Refer to PART 3
  
• I need to add or delete a PEP on a service location on my provider file - Refer to PART 4
  

I have relocated my practice and need to update my provider file: Provider Practice Relocation Request

I need to assign my fees to my employer: Individual Request for Assignment of Fees

I need more information about Provider Eligibility Programs (PEPs): Provider Eligibility Program (PEP) Descriptions

My company has had a change of ownership or control interest:

• *WITHOUT* a change in the enrolled IRS tax number: Complete the Ownership and Control Interest Form
  1. Do not submit only the changed information - The form must be completed to show the ownership/control structure as it will be after the transaction takes place.
  2. Only one form should be submitted *per* tax id (not per service location, NPI, etc.). Make sure you complete Section I (Managing Employee) for *each* service location under the tax id.
  3. A copy of the sales agreement is also required for home and community-based waiver providers and nursing facilities.
• *WITH* a change in the enrolled IRS tax number: Please submit the following:
  1. A signed letter with the following information:
     1. Statement of the change that will take place (e.g. – merger, acquisition, etc.)
     2. The current tax ID, IRS name and MA provider number (s)
     3. The new tax ID number and IRS name
     4. The anticipated or actual effective date of the transaction
     5. Contact name with phone number and/or e-mail
  2. Copy of the sales agreement for home and community-based waiver providers and nursing facilities
  3. Enrollment application, with requirements, for the appropriate provider type with the ownership and control interest form completed (included as part of the enrollment application.)

All documents and inquiries related to changes of ownership/control interest, officers/board members, tax id, etc. should be sent to RA-pwProvCHOW@pa.gov

If you have any other enrollment-related questions, please call the appropriate phone number shown on the Medical Assistance Desk Reference