Provider Enrollment and Screening Requirements of the Affordable Care Act
Have you had a claim(s) denied or not received payment for a claim submitted after September 25, 2016? If you did not revalidate and you enrolled in the Medical Assistance program prior to September 25, 2011, you may have been dis-enrolled, per Medical Assistance Bulletin 99-16-10. To re-enroll please submit a revalidation (re-activation application if you are submitting via the Electronic Provider Enrollment Portal) application as soon as possible. The effective date of your re-enrollment will be when DHS has received your complete revalidation application.
The Department of Human Services (DHS) is in the midst of implementing the Provider Enrollment and Screening Provisions of the Affordable Care Act (ACA) (§ 455.414).
All providers must revalidate their Medical Assistance enrollment every 5 years. Providers should log into PROMISe to check their revalidation date and submit a revalidation application at least 60 days prior.
Providers will need to complete a full new enrollment application for their provider type for each site of service (service location).
If you have already submitted your revalidation application, DHS will send out a change notice when your application is processed and the service location is revalidated.
Changes to Medical Assistance (MA) Provider Enrollment & Screening
The ACA contains several program integrity provisions for provider screening and enrollment. The requirements are as follows:
- States must require all providers to be screened in accordance with their risk level (limited, moderate, high). For more information, please see Medical Assistance Bulletin 99-16-13, Assignment of ACA Categorical Risk Levels and the Implementation of Site Visits.
- States must verify that the provider is licensed by the State, that the license has not expired and does not have any current limitations
- Providers must consent to criminal background checks, including fingerprinting
- States must revalidate the enrollment of all providers at least every 5 years. For more information, please see Medical Assistance Bulletin 99-16-10, Revalidation of Medical Assistance (MA) Providers.
- States must collect an application fee prior to executing a provider agreement from a prospective or re-enrolling provider except for the following:
- Individual physicians or non-physician practitioners
- Providers who are enrolled in Title XVIII of the Act or Another State's title XIX or XXI plan
- Providers that have paid the applicable application fee to a Medicare contractor or another state. For more information on the application fee, please see the Medical Assistance Bulletin titled ACA Enrollment Application Fee.
- States must terminate the enrollment of any provider where any person with a 5% or greater direct or indirect ownership interest in the provider did not submit timely and accurate information and cooperate with any screening method
- States must deny enrollment of any provider that is terminated on or after January 1, 2011, under title XVIII of the Act or under the Medicaid program or CHIP of any other State
- States must give providers who are terminated or denied, appeal rights under the State law and regulations
- States must conduct site visits to verify that the information submitted to the State is accurate and determine compliance with the Federal and State enrollment requirements. For more information, please see Medical Assistance Bulletin 99-16-13, Assignment of ACA Categorical Risk Levels and the Implementation of Site Visits.
- States must require any enrolled provider to permit CMS, its agents, its designated contractors, or the State Medicaid agency to conduct unannounced on-site inspections of any and all provider locations
- States may impose temporary moratoria on enrollment of new providers, or impose numerical caps or other limits that the State Medicaid agency identifies as having a significant potential for fraud, waste or abuse and that the Secretary has identified as being at high risk for fraud, waste, or abuse
- States must require all claims for payment for items and services that were ordered or referred contain the NPI of the provider who ordered or referred such items. For more information, please see Medical Assistance Bulletin 99-16-07 Enrollment of Ordering, Referring and Prescribing Providers.
What is DHS doing to help?
To help expedite and streamline the provider enrollment process, DHS launched the following initiatives:
- Standardization of Policies and Procedures: DHS is developing a department-wide approach to provider enrollment to help reduce the variations across program offices that causes confusion.
- Staffing: DHS added temporary staff to help process provider enrollment applications and eliminate backlogs.
- Online Application: Providers are now able to enroll through the electronic provider enrollment application. Click here to submit an enrollment or revalidation application.
- NOTE: ODP Intellectual Disabilities’ Providers should continue to submit their enrollment applications for new service locations and revalidation applications of current service locations via paper format. For more information regarding revalidation, review ODP Announcement # 098-15.
"DHS believes that good customer service is critical to delivering quality services to our clients and we know that we must do a better job helping providers enroll if we are going to meet that goal." - Secretary Ted Dallas
Frequently Asked Questions
You may have already revalidated! Check the MA Enrolled Provider Portal Lookup Function – at www.promise.dpw.state.pa.us. All provider letters and portal login screens contain your next revalidation due date. Look for changes on the provider portal for each 13-digit logon to check your service location.