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

Tips to navigate the portal - User Interface Provider Training.
 

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:
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. 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:
a) Statement of the change that will take place (e.g. – merger, acquisition, etc.)
b) The current tax ID, IRS name and MA provider number (s)
c) The new tax ID number and IRS name
d) The anticipated or actual effective date of the transaction
e) 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 

 To access enrollment or revalidation applications and requirements for each Medical Assistance provider type visit the Provider Enrollment Documents page.

 

 

 

 

 

PROMISe™ Provider Type
(Code and Description)
Enrollment Documents
01 - Inpatient Facility:

 
 
Acute Care Hospital
 
*Short Procedure Unit Requirements
 
*Inpatient Psychiatric
 
* Inpatient Drug & Alcohol Rehabilitation
 
*Inpatient Medical Rehabilitation
 
*JCAHO Certified RTF (Residential Treatment Facility)
 
 
 
 
 
 
02 - Ambulatory Surgical Center* Enrollment Application / Provider Agreement
* ASC Requirements
03 - Extended Care Facility* Enrollment Application
* Requirements
* Special Provider Agreement for Change of Ownerships
04 - Rehabilitation Facility*Enrollment Application / Provider Agreement
* Rehabilitation Facility Requirements
05 - Home Health Agency* Enrollment Application / Provider Agreement
* Home Health Agency Requirements
06 - Hospice* Enrollment Application / Provider Agreement
* Hospice Requirements
07 - Capitation* Enrollment Application / Provider Agreement
* Capitation Requirements

08 - Clinic 

* Federally Qualified Health Center

* Rural Health Clinic

* Non-FQHC/RHC Clinics
 

 

 
 
 
 
 
 
09 - Certified Registered Nurse Practitioner (CRNP)* Enrollment Application / Provider Agreement
* CRNP Requirements
* CRNP Group Application
10 - Midlevel Practitioner

11 - Mental Health/Substance Abuse Services Provider

*Mental Health/Substance Abuse Providers

*Social Worker

*Mental Health/Substance Abuse Provider Requirements

*Social Worker Requirements 

12 - School Corporation* Enrollment Application / Provider Agreement
* School Corporation Requirements
14 - Podiatrist* Enrollment Application / Provider Agreement
* Podiatrist Requirements
* Podiatrist Group Application
15 - Chiropractor* Enrollment Application / Provider Agreement
* Chiropractor Requirements
* Chiropractor Group Application
16 - Nurse* Enrollment Application / Provider Agreement
* Nurse Requirements
* Nurse Group Application
17 - Therapist* Enrollment Application / Provider Agreement
* Therapist Requirements
* Therapist Group Application
18 - Optometrist* Enrollment Application / Provider Agreement
* Optometrist Requirements
* Optometrist Group Application
19 - Psychologist* Enrollment Application / Provider Agreement
*Psychologist Requirements
* Psychologist Group Application
20 - Audiologist* Enrollment Application / Provider Agreement
* Audiologist Requirements
* Audiologist Group Application
21 - Case Manager* Enrollment Application / Provider Agreement
*Case Manager Requirements
23 - Nutritionist* Enrollment Application / Provider Agreement
* Nutritionist Requirements
*Nutritionist Group Application
24 - Pharmacy
25 - Durable Medical Equipment/Medical Supplies
26 - Transportation Provider* Enrollment Application / Provider Agreement
* Transportation Requirements
27 - Dentist* Enrollment Application / Provider Agreement
* Dentist Requirements
* Dentist Group Application
28 - Laboratory* Enrollment Application / Provider Agreement
* Laboratory Requirements
29 - Mobile X-ray Clinic* Enrollment Application / Provider Agreement
* Mobile X-ray Clinic Requirements
30 - Renal Dialysis Clinic*Enrollment Application / Provider Agreement
* Renal Dialysis Clinic Requirements
31 - Physician/Physician Group
32 - Certified Registered Nurse Anesthetist (CRNA)* Enrollment Application / Provider Agreement
* CRNA Requirements
* CRNA Group Application
33 - Certified Nurse Midwife* Enrollment Application / Provider Agreement
* Certified Nurse Midwife Requirements
* Certified Nurse Midwife Group Application
35 - Public School* Enrollment Application / Provider Agreement
* Public School Requirements
37 - Tobacco Cessation Provider* Enrollment Application / Provider Agreement
* Tobacco Cessation Provider Requirements
40 - Medically Fragile Foster Care Provider* Enrollment Application / Provider Agreement
* Medically Fragile Foster Care Provider Requirements
43 - Homemaker Agency*Enrollment Application / Provider Agreement
* Homemaker Agency Requirements
47 - Birthing Center* Enrollment Application / Provider Agreement
* Birthing Center Requirements
51 - Home and Community Habilitation* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
51 - CSPPPD Provider

*Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Enrollment Checklist
* Region Breakdown
* Regional Rate Sheet

52 - Community Residential Rehabilitation* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
53 - Employment Competitive* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
54 - Intermediate Service Organization* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms

55 - Vendor

* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms

56 - Residential Treatment Facility (RTF) - Non-JCAHO Certified* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
58 - Interpreter* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
59 - OLTL Programs

* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Enrollment Checklist
* Region Breakdown
* Regional Rate Sheet 
*HCBS Provider Agreement

66 - Funeral Director* Enrollment Application / Provider Agreement
*Funeral Director Requirements