State · PA
Medical billing services in Pennsylvania
Short answer
Medical billing services in Pennsylvania have to split one Medicaid member across three programs: a Physical HealthChoices MCO chosen by zone, a county-assigned BH-MCO for mental health and substance use, and Community HealthChoices for dual eligibles and adults who need long-term supports, each with its own payer ID, authorizations and filing rules.
Fee-for-service claims go to PROMISe within 180 days, Act 68 gives plans 45 days to pay a clean claim, and EVV runs on an open model through the DHS Aggregator. Remitwright assigns a dedicated biller who works those rules on every claim, serving Pennsylvania practices remotely. Rules for other states are on the medical billing services by state page.
Last reviewed by the Remitwright billing team. Editorial policy
Billing in Pennsylvania: what's different
The rules below change how a claim is filed and paid in Pennsylvania. Each line links to the official page it was read from, and the date at the top of this page is when it was last checked.
| Fact | In Pennsylvania | Source |
|---|---|---|
| Medicaid program | Medical Assistance (MA)Pennsylvania Department of Human Services (DHS) | 1 |
| Fee-for-service portal | PROMISe provider portal | 1 |
| Managed care plans | 8 plansAmeriHealth Caritas Pennsylvania, AmeriHealth Caritas Northeast, Geisinger Health Plan, Jefferson Health Plans EverWell, Highmark Wholecare, UPMC for You, Keystone First, UnitedHealthcare Community Plan | 3 |
| Medicaid timely filing (fee-for-service) | 180 days from the date of service | 2 |
| Prompt-pay law | Act 68 of 1998 (40 P.S. § 991.2166), implemented by 31 Pa. Code § 154.18 | 6 |
| NEMT | Medical Assistance Transportation Program (MATP) | 9 |
| EVV | Open model | 10 |
Medical Assistance (MA)
Medical Assistance (MA) is run by the Pennsylvania Department of Human Services (DHS). Fee-for-service claims and provider enrollment go through the PROMISe provider portal1, at promise.dhs.pa.gov. Physical HealthChoices: Medical Assistance physical health runs through managed care organizations contracted by zone (Lehigh/Capital, Northeast, Northwest, Southeast and Southwest), so the plans available, and the payer IDs you bill, depend on the member's county3. Mental health and drug and alcohol services are carved out to Behavioral HealthChoices, and dual eligibles and adults who need long-term services and supports are enrolled in Community HealthChoices. Both are described in the rules below.
Fee-for-service filing limit: 180 days from the date of service for an original fee-for-service claim to be received by the Department; rejected claims and adjustments must be resubmitted within 365 days of the date of service2. 55 Pa. Code § 1101.68. Nursing facilities and ICF/MR providers count both limits from the last day of the billing period. This rule governs claims billed to PROMISe; for a HealthChoices plan or BH-MCO, use the filing limit in that plan's provider manual or contract.
Managed care plans3
- AmeriHealth Caritas PennsylvaniaLehigh/Capital, Northwest and Southwest zones
- AmeriHealth Caritas NortheastNortheast zone
- Geisinger Health PlanAll five zones
- Jefferson Health Plans EverWellAll five zones
- Highmark WholecareLehigh/Capital and Southwest zones
- UPMC for YouAll five zones
- Keystone FirstSoutheast zone
- UnitedHealthcare Community PlanSoutheast zone
Each plan is credentialed separately, has its own portal and its own appeal route. A practice that joins Pennsylvania Medicaid through one plan is not in network with the others until each contract is in place.
Commercial payers and the prompt-pay law
The largest commercial payers in Pennsylvania by reported market share8: Keystone Health Plan East, Independence Assurance Company, UPMC Health Network, Highmark Inc., Capital Advantage Assurance Company, Health Partners Plans, Geisinger Health Plan, Ambetter Health of Pennsylvania. Each has its own filing window, corrected-claim process and appeal levels in its provider manual, and the timely filing limits table lists verified payer deadlines with their sources.
Clean-claim payment window under Act 68 of 1998 (40 P.S. § 991.2166), implemented by 31 Pa. Code § 154.18: 45 days from receipt of a clean claim6. Applies to licensed insurers and managed care plans for services since January 1, 1999, not to automobile or workers' compensation policies. Interest on a late clean claim is added to the amount owed and must be paid within 30 days of the claim payment; interest under $2 on a claim is not owed. For a Pennsylvania practice, the statute does its work in A/R follow-up: a clean claim still unpaid after the window is escalated with the statute cited, and interest is requested where the law provides it.
NEMT and home care in Pennsylvania
Non-emergency medical transportation. Medical Assistance Transportation Program (MATP): non-emergency rides at no cost for Medical Assistance recipients with an unmet transportation need, arranged through county MATP offices, which provide the least costly appropriate option (van, taxi or accessible vehicle) or reimburse bus fare, mileage and tolls9. MATP covers travel to any service Medicaid pays for, including pharmacy pickups and medical equipment suppliers. The state page names no statewide broker; the county MATP office is the point of contact, and the member's signed application must reach that office within 30 days of eligibility verification. The NEMT billing in Pennsylvania page covers trip documentation, broker claims and reconciliation.
Electronic visit verification. Open model. DHS offers its own EVV system, built with Gainwell Technologies and Sandata and integrated with PROMISe, but a provider may use an alternate EVV vendor if the system captures the six data elements required by the Cures Act and interfaces with the DHS Aggregator10. Required for Medicaid-funded personal care services (PCS) and home health care services (HHCS) under section 12006 of the 21st Century Cures Act. Technical specifications for the aggregator interface are published on the DHS Alternate EVV page. See home care billing in Pennsylvania for waiver programs, EVV exceptions and authorizations.
Rules that change how Pennsylvania claims are billed
Behavioral health is carved out to county BH-MCOs5
Mental health and drug and alcohol services under HealthChoices do not go to the physical health plan. Each county contracts with a behavioral health managed care organization, and every HealthChoices member is assigned a BH-MCO by county of residence: Community Care Behavioral Health, PerformCare, Magellan Behavioral Health, Carelon or, in Philadelphia, Community Behavioral Health. Credentialing, authorizations and claims for therapy, psychiatry and substance use treatment go to that BH-MCO, with its own payer ID.
Community HealthChoices for dual eligibles and LTSS4
People eligible for both Medicaid and Medicare, and adults 21 or older with physical disabilities, are enrolled in Community HealthChoices, the long-term services and supports managed care program. Three CHC plans operate: AmeriHealth Caritas, PA Health & Wellness and UPMC Community HealthChoices. A home care agency or practice serving these members deals with the member's CHC plan, so eligibility checks have to identify CHC enrollment before the first visit.
Act 42 of 2024 sets telemedicine coverage and payment11
Health insurance policies with forms or rates filed on or after March 31, 2025 must cover medically necessary services delivered through telemedicine by a participating network provider, and reimbursement may not be denied solely because the service was provided through telemedicine; the rate itself may still vary by contract and plan. From January 1, 2026, Medical Assistance and CHIP managed care plans must pay for medically necessary telemedicine services that meet the conditions in the act.
Surprise billing complaints go to the Pennsylvania Insurance Department12
The Insurance Department publishes the federal No Surprises Act protections for Pennsylvania patients. Emergency services at a hospital, hospital outpatient department or ambulatory surgical center, or by air ambulance, must be covered without prior approval regardless of network status, and an out-of-network lab or pathologist at an in-network facility is covered at the in-network rate. Patients who believe they were wrongly billed are directed to the Department, so a practice's balance-billing process has to match these rules.
Revalidation runs through PROMISe, one service location at a time13
Each active service location under a 9-digit provider ID carries its own revalidation date. Providers can download an extract from PROMISe listing every service location with its 13-digit provider ID, NPI, revalidation date, provider type, specialties and taxonomy codes. The Electronic Revalidation Application is reached from the My Home page of the PROMISe Provider Portal, and a provider closed for more than two years can reach it from the portal home page without logging in.
Act 68 fixes the interest on late clean claims in statute7
The prompt pay regulation at 31 Pa. Code § 154.18 implements Act 68 of 1998, the Quality Health Care Accountability and Protection Act. During the rulemaking, provider groups asked the Insurance Department to write a higher interest rate into the regulation; the Department answered that the interest rate and the $2 minimum are set by section 2166(a) of the act itself and cannot be changed by regulation. The interest is owed on the clean claim, so your biller needs the plan's receipt date for every claim, not just the submission date.
Services for Pennsylvania practices
Remitwright serves Pennsylvania practices remotely, inside the practice management or EHR system the practice already uses. A dedicated biller works the account; nothing is pooled. Each service below explains what that biller does.
- Medical billingClaims worked by one named biller
- CredentialingEnrollment, CAQH and PECOS kept current
- Eligibility verificationCoverage and benefits checked before visits
- Prior authorizationAuths requested, tracked, attached to claims
- Denial managementEvery denial read, worked and appealed
- A/R follow-upUnpaid claims chased before filing limits
FAQ
Questions from Pennsylvania practices
What is the timely filing limit for Pennsylvania Medical Assistance?
Who do I bill for a HealthChoices patient's therapy or substance use visits?
Which commercial payers matter most in Pennsylvania, and where does that list come from?
How long does a Pennsylvania plan have to pay a clean claim?
Do we have to use the state's EVV system for our Pennsylvania home care agency?
Does Pennsylvania pay for telehealth at the same rate as an office visit?
We enrolled in Medical Assistance. Does that put us in the HealthChoices plans too?
Who pays for a Medicaid patient's ride to our office in Pennsylvania?
Which managed care plans run Medicaid in Pennsylvania?
Who runs Medicaid in Pennsylvania, and where do fee-for-service claims go?
Next step
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