CHIP Provider Enrollment Information
The Department of Human Services (Department) is implementing the Affordable Care Act (ACA) Provider Screening and Enrollment provisions which require all providers who render services to CHIP enrollees to be enrolled with the Department of Human Services. To enroll, providers must complete an enrollment application appropriate for their provider type and submit all required documents. If a provider is already enrolled in the Pennsylvania Medical Assistance program, the provider does not need to enroll again in CHIP.
 
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.

If you are an individual provider who has been placed in the “high” categorical risk level, please visit the IdentoGo website and follow the instructions provided for obtaining a fingerprint-based criminal background check.
 
If you are the owner of a provider that has been placed in the “high” categorical risk level, please visit the IdentoGo website and follow the instructions provided for obtaining a fingerprint-based criminal background check.
 
Please note that if the banner at the top of the screen does not read OMAP – Medical Assistance Provider Direct/Indirect Ownership Interest or OMAP – Medical Assistance Provider, your background check information will be sent to the wrong office and you will have to re-register.
 
Once registered, you will be assigned a registration code. Please enter that code and the date of your screening into the Electronic Provider Portal application.
 
If you have not received a letter from the Department supplying you with a voucher code but you believe you are subject to the criminal background check screenings, please call the Department at 1.800.537.8862 option 3, option 1, option 1, then option 4 to speak with the Fingerprint-Based Criminal Background Check team.
 
To obtain a Pennsylvania State Police Criminal Record Check, visit the Pennsylvania State Police Criminal Record Check website. The 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 and submit these results directly to the Department.
 
Enroll Electronically 
 
CHIP 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. Please check if the provider type has additional requirements that must be included with the application. Click here for a list of provider types and specialties for CHIP providers/CHIP Provider Crosswalk.
 
All enrollment documents are in Adobe PDF format. You must have a copy of Adobe Acrobat Reader installed on your system to view them. 
 
For questions, please call Provider Enrollment at 1-800-537-8862 and select option 3, then option 1, option 1 and option 4.
 
CHIP Provider Type
(Code and Description)
Enrollment Documents
01 - Inpatient FacilityCHIP ONLY Facility/Agency
Enrollment Application
 
02 - Ambulatory Surgical CenterCHIP ONLY Facility/Agency
Enrollment Application

 
03 - Extended Care FacilityCHIP ONLY Facility/Agency
Enrollment Application

 
04 - Rehabilitation FacilityCHIP ONLY Facility/Agency
Enrollment Application

 
05 - Home Health AgencyCHIP ONLY Facility/Agency
Enrollment Application

 
06 - HospiceCHIP ONLY Facility/Agency
Enrollment Application

 
07 - CapitationCHIP ONLY Facility/Agency
Enrollment Application

 
08 - Clinic  
 
Including:
 
* Federally Qualified Health Center
* Rural Health Clinic
* Non-FQHC/RHC Clinics
CHIP ONLY Facility/Agency
Enrollment Application

 
09 - Certified Registered Nurse Practitioner (CRNP)
10 - Midlevel Practitioner
Including:
Physician Assistants
Public Health Dental Hygienist
Acupuncturists
 
CHIP ONLY Individual Provider Application
11 - Mental Health/Substance
Abuse Services Provider
 
 
Mental Health/Substance Abuse Providers
 
 
OR
 
 14 - Podiatrist
 15 - ChiropractorCHIP ONLY Individual Provider Application
CHIP ONLY Group Provider Application
 
 16 - NurseCHIP ONLY Individual Provider Application
CHIP ONLY Group Provider Application 
 
 17 - TherapistCHIP ONLY Individual Provider Application
CHIP ONLY Group Provider Application
 
 18 - OptometristCHIP ONLY Individual Provider Application
CHIP ONLY Group Provider Application 
 
 19 - Psychologist
 20 - Audiologist
 21 - Case Manager
 23 - Nutritionist
 24 - Pharmacy
 25 - Durable Medical Equipment/Medical Supplies
 26 - Transportation Provider
 27 - Dentist
 28 - Laboratory

**Additional requirements for Laboratories

 29 - Mobile X-ray Clinic and IDTF
 30 - Renal Dialysis ClinicCHIP ONLY Facility/Agency
Enrollment Application

**Additional Requirements for Renal Dialysis Clinic
 31 - Physician/Physician Group
 32 - Certified Registered Nurse Anesthetist (CRNA)
 33 - Certified Nurse Midwife
 37 – Tobacco Cessation
 47 – Birth Center