PROMISe Provider Enrollment

In order for providers to participate with the Department of Human Services (DHS), 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.
  Please Note: Enrollment in state Medicaid does not guarantee enrollment in individual MCO Networks. New providers should contact each MCO directly to explore their provider network needs as some MCO provider networks may be closed due to network adequacy.

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

Instructions for navigating the portal - use the Online Provider Enrollment portal to view the Internet Help Manual.

Criminal Background Check

DHS 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 five 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 MA Bulletin 99-17-03 or visit the Office of Medical Assistance Programs (OMAP) section of the Provider Clearances and Background Checks page.

Enrollment Forms

• PROMISe™ Service Location Change Request and Instructions— Use 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)
    

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

  - Without a change in the enrolled IRS tax number:

  • Complete the Ownership and Controled Interest Form.
    • Do no submit on the changed information — The form must be completed to show the ownership/control structure as it will be after the transaction takes place.
      
    • Only one form should be submitted per tax ID (not per service location, NPI, etc.). Make sure to complete Section I (Managing Employee) for each service locaiton under the tax ID.
    • 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:

    • A signed letter with the following information:
      • Statement of the change that will take place (e.g., merger, acquisition)
        
      • Current tax ID, IRS, name, and MA provider number(s)
      • The new tax ID number and IRS name
      • The anticipated or actual effective date of the transaction
      • Contact name with phone number and/or email

      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