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Provider enrollment information 

In order for providers to participate with the Department of Human Services, they must first enroll. To enroll, providers must complete an enrollment application appropriate for their provider type and submit all required documents necessary for that provider type.
  • To be eligible to enroll, practitioners 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.  
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 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.
 
To obtain a FBI criminal background check, please visit the website and follow the instructions provided for obtaining a fingerprint-based criminal background check for Pennsylvania Department of Human Services, Medical Assistance providers. The registration number and the date selected to have fingerprints taken need to be reported to the Department. Please record this information
 
Please Note: If you are a provider and or qualified owner seeking to register for fingerprinting via the Cogent website please make sure you enter the correct registration portal by selecting the DHS icon that states “Office of Medical Assistance Programs Fee for Service Provider Enrollment”. Once there, check the URL to make sure it states https://pacogentid.3m.com/index_omap.htm. When registering, the only reason for fingerprinting option should be “Medical Assistance Provider”. If this option does not display, use your browser’s back button to return to the original page and select the correct DHS icon that states “DHS Office of Medical Assistance Programs Fee For Service Provider Enrollment”.
 
To obtain a Pennsylvania State Police Criminal Record Check, visit the Pennsylvania State Police Criminal Record Check websiteThe department will request the results of the State Police Criminal Record Check from the provider and any person with a 5 percent or greater ownership interest in the provider. Please retain the results for submission to the department.
 
Enroll electronically

Providers are now able to enroll through the electronic provider enrollment application. The benefits of using the secure online portal are:

Enroll on paper 

The table below contains links to applicable provider enrollment forms for each provider type. Print the documents for your provider type and follow the instructions for completing the documents. To enroll, providers must complete an enrollment application appropriate for their provider type and submit all required documents necessary for that provider type. 

 All enrollment documents are in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view them. 

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

 
 
Acute Care Hospital
 
*Inpatient Psychiatric
 
* Inpatient Drug & Alcohol Rehabilitation
 
*Inpatient Medical Rehabilitation
 
*JCAHO Certified RTF (Residential Treatment Facility)
 
*Hospital Based Medical Clinic
 
*Short Procedure Unit
 
 
 
 
 
 
 
02 - Ambulatory Surgical CenterEnrollment Application / Provider Agreement
ASC Requirements
03 - Extended Care FacilityEnrollment Application
Requirements
Special Provider Agreement for Change of Ownerships
04 - Rehabilitation Facility*Enrollment Application / Provider Agreement
Rehabilitation Facility Requirements
05 - Home Health AgencyEnrollment Application / Provider Agreement
* Home Health Agency Requirements
06 - HospiceEnrollment Application / Provider Agreement
Hospice Requirements
07 - CapitationEnrollment 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 CorporationEnrollment Application / Provider Agreement
School Corporation Requirements
14 - PodiatristEnrollment Application / Provider Agreement
Podiatrist Requirements 
Podiatrist Group Application
15 - ChiropractorEnrollment Application / Provider Agreement
Chiropractor Requirements
Chiropractor Group Application
16 - NurseEnrollment Application / Provider Agreement
Nurse Requirements
Nurse Group Application
17 - TherapistEnrollment Application / Provider Agreement
Therapist Requirements
Therapist Group Application
18 - OptometristEnrollment Application / Provider Agreement
Optometrist Requirements
Optometrist Group Application
19 - PsychologistEnrollment Application / Provider Agreement
*Psychologist Requirements
Psychologist Group Application
20 - AudiologistEnrollment Application / Provider Agreement
Audiologist Requirements 
Audiologist Group Application
21 - Case ManagerEnrollment Application / Provider Agreement
*Case Manager Requirements
23 - NutritionistEnrollment Application / Provider Agreement
Nutritionist Requirements
*Nutritionist Group Application
24 - Pharmacy
25 - Durable Medical Equipment/Medical Supplies
26 - Transportation ProviderEnrollment Application / Provider Agreement
Transportation Requirements
27 - DentistEnrollment Application / Provider Agreement
Dentist Requirements
Dentist Group Application
28 - LaboratoryEnrollment Application / Provider Agreement
Laboratory Requirements
29 - Mobile X-ray ClinicEnrollment Application / Provider Agreement
Mobile X-ray Clinic Requirements
30 - Renal Dialysis ClinicEnrollment 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 MidwifeEnrollment Application / Provider Agreement
Certified Nurse Midwife Requirements 
Certified Nurse Midwife Group Application
35 - Public SchoolEnrollment Application / Provider Agreement
Public School Requirements
37 - Tobacco Cessation ProviderEnrollment Application / Provider Agreement
Tobacco Cessation Provider Requirements
40 - Medically Fragile Foster Care ProviderEnrollment Application / Provider Agreement
Medically Fragile Foster Care Provider Requirements
43 - Homemaker Agency*Enrollment Application / Provider Agreement
Homemaker Agency Requirements
47 - Birthing CenterEnrollment Application / Provider Agreement
Birthing Center Requirements
51 - Home and Community HabilitationEnrollment 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 RehabilitationEnrollment Application / Provider Agreement
Requirements / Additional Information / Forms
53 - Employment CompetitiveEnrollment Application / Provider Agreement
Requirements / Additional Information / Forms
54 - Intermediate Service OrganizationEnrollment Application / Provider Agreement
Requirements / Additional Information / Forms
55 - Vendor

 

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

56 - Residential Treatment Facility (RTF) - Non-JCAHO CertifiedEnrollment Application / Provider Agreement
RTF Requirements
58 - InterpreterEnrollment 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 DirectorEnrollment Application / Provider Agreement
*Funeral Director Requirements

 

Additional Enrollment Forms

I need to close a service location on my provider file: PROMISe™ Service Location Change Request and Instructions; Block #1
 
I need to change the mailing, payment and/or 1099 address for an existing service location on my provider file:
PROMISe™ Service Location Change Request and Instructions; Block #2

I have relocated my practice and need to update my provider fileProvider Practice Relocation Request

 
I need to assign my fees to my employerIndividual Request for Assignment of Fees
 
I need to terminate an assignment of fees: PROMISe™ Service Location Change Request and Instructions; Block #3
 

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

 
My company has had a change of ownership *without* a change in the IRS tax number: Ownership and Control Interest Form
 
My company has had a change of ownership *WITH* a change in the IRS tax number:
Please call Melissa Fetzer at (717) 257-5217 to discuss what documents will be needed.
 
If you have any questions about completing any of the documents, please call the appropriate phone number shown on the Important Phone Numbers and Addresses page of this site.