Enrollment Information
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 99-16-06. 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
A successfully completed application will have the following items:
  • Ownership and controlling interest section completed
  • Signed application
  • Include all attachments
If you received a returned application from DHS, one or more of the above items were not complete.
Once providers have been re-enrolled they may submit claims for services provided as of the effective date of the enrollment.

 
 

NOTICE TO PROVIDERS SUBMITTING APPLICATIONS THROUGH THE ELECTRONIC PROVIDER ENROLLMENT PORTAL (online application): Several email service carriers are preventing emails from the Electronic Provider Enrollment Portal from getting to the intended recipients. The following companies are blocking all emails sent from the electronic provider enrollment portal: AOL, VERIZON, ZOOMINTERNET, COMCAST, USPI, WINDSTREAM and AIM. We are troubleshooting this issue to allow these emails to reach providers.


In order for providers to participate with the Department of Human Services, 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. To enroll, providers must complete a Base Provider Enrollment form and any applicable addenda documents dependent on the provider type.

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.

Enroll electronically

Providers are now able to enroll through the electronic provider enrollment application found here. 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.

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.

View Frequently Asked Questions

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

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 file: Provider Practice Relocation Request

 
I need to assign my fees to my employer: Individual 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.
 

 

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)
 
 
 
 
 
02 - Ambulatory Surgical Center* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
03 - Extended Care Facility* Enrollment Application
* Requirements
* Special Provider Agreement for Change of Ownerships
04 - Rehabilitation Facility*Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
05 - Home Health Agency* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
06 - Hospice* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
07 - Capitation* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms

08 - Clinic 

* Federally Qualified Health Center

* Rural Health Clinic

* Non-FQHC/RHC Clinics
 

 

 
 
 
 
 
 
09 - Certified Registered Nurse Practitioner (CRNP)* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
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 Corporation* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
14 - Podiatrist* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
15 - Chiropractor* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
16 - Nurse* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
17 - Therapist* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
18 - Optometrist* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
19 - Psychologist* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
20 - Audiologist* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
21 - Case Manager* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
23 - Nutritionist* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
24 - Pharmacy
25 - Durable Medical Equipment/Medical Supplies
26 - Transportation Provider* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
27 - Dentist* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
28 - Laboratory* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
29 - Mobile X-ray Clinic* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
30 - Renal Dialysis Clinic* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
31 - Physician/Physician Group* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
* Telehealth Maternal-Fetal Specialist
32 - Certified Registered Nurse Anesthetist (CRNA)* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
33 - Certified Nurse Midwife* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
* Group Enrollment Application and Requirements
35 - Public School* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
36 - Personal Care Services Provider* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
37 - Tobacco Cessation Provider* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
40 - Medically Fragile Foster Care Provider* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
43 - Homemaker Agency* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
47 - Birthing Center* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
51 - Home and Community Habilitation* Enrollment 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 Rehabilitation* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
53 - Employment Competitive* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
54 - Intermediate Service Organization* Enrollment 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 Certified* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms
58 - Interpreter* Enrollment 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

66 - Funeral Director* Enrollment Application / Provider Agreement
* Requirements / Additional Information / Forms