Use the Online Provider Enrollment portal to submit a new application, for revalidation, or for reactivation.
Benefits of using the secure online portal:
Tips to navigate the portal - User Interface Provider Training.
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 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.
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.govIf 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.