State Guide

Credentialing in Pennsylvania

Enrollment guides for 55 payers operating in Pennsylvania.

What actually differs in Pennsylvania

Credentialing advice written for "most states" tends to be wrong here in specific, expensive ways. These are the rules that only apply in Pennsylvania.

5 sourced rules, each linked to its source

Getting enrolled 3 Rules that decide your timeline 1 Who on your team can bill 1

5 sourced rules

Every claim on this page links to the statute, rule or agency page it came from. Last checked July 2026.

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County-based BH-MCO carve-out (the multiplier)

Pennsylvania's defining trap: behavioral health is a mandatory carve-out assigned by the member's county of residence to a county-contracted BH-MCO, not the physical-health plan. The five BH-MCOs: Community Behavioral Health (Philadelphia only), Community Care Behavioral Health (~38 counties), Magellan BH of PA (7 southeast counties), PerformCare (7 south-central), and Carelon Health of PA (11 western counties). A BH group serving multiple counties must contract a different BH-MCO per county footprint. Adding one county can mean a whole new credentialing cycle, and this per-county burden is the single biggest stall in Pennsylvania.

PA DHS Behavioral Health MCOs via kb/states/pa.md · checked Jul 2026

PROMISe + HealthChoices dual layer

Pennsylvania Medical Assistance enrollment runs through PROMISe, and because PA is near-fully managed care (HealthChoices), a solo provider enrolls in PROMISe AND contracts with the physical-health MCOs for their zone AND the county behavioral-health MCO. MCO network providers must be PROMISe-enrolled first.

PA DHS PROMISe Provider Enrollment via kb/states/pa.md · checked Jul 2026

Revalidation (5 years per service location) PA MA Bulletin 99-16-10

All Pennsylvania Medical Assistance providers revalidate every 5 years per service location, submitting at least 60 days prior (MA Bulletin 99-16-10). Note the corrected record: PA has NO shorter revalidation cycle for high-risk providers, high categorical risk triggers additional screening (FBI + PA State Police background checks), not a shorter interval.

PA DHS MA Bulletin 99-16-10 via kb/states/pa.md · checked Jul 2026

Act 68 prompt pay (45 days, 10% interest) 31 Pa. Code § 154.18

Pennsylvania's Act 68 of 1998 requires plans to pay clean claims within 45 days, with 10% annual interest on late payment (31 Pa. Code § 154.18). Act 68 mandates written credentialing criteria and reasoned denial notices but sets NO hard credentialing turnaround deadline. It is a prompt-pay law, not a prompt-credentialing law.

PA Insurance Dept. Act 68 fact sheet via kb/states/pa.md · checked Jul 2026

Pre-licensed billing (facility-only, degree-based) 55 Pa. Code Chs. 1153, 5200 (49 Pa.B. 5952)

Pennsylvania doesn't run on license tiers, it runs on degree-based clinic staffing. MA payment for outpatient psychotherapy goes to licensed psychiatric outpatient clinics, where 'mental health professional' is defined by graduate degree with clinical practicum, NOT licensure, so a pre-licensed master's counselor or LSW qualifies, and even bachelor's staff count as mental health workers under supervision. The clinic bills, a psychiatrist supervises (at least 50% of psychotherapy staff must be MHPs, plus 2 hours of psychiatric time per week per FTE), and there is no individual-enrollment or supervisor-renders path for pre-licensed clinicians in solo or group practice.

55 Pa. Code Chs. 1153/5200 final-form text via kb/states/pa.md · checked Jul 2026

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A credentialing manager files the applications, chases the payers and tracks your recredentialing dates.

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Who Runs Pennsylvania Medicaid Provider Enrollment

50-state research

Enrollment Portal

PROMISe provider portal

Operated By

Gainwell Technologies

Platform

PROMISe

From PayerReady's 50-state Medicaid enrollment platform research, verified July 2026. Portal contracts change; where an operator is in transition or not publicly confirmed, we say so rather than guess.

Aetna

Aetna (CVS Health)

Credentialing in Pennsylvania

What actually differs in Pennsylvania

Who Runs Pennsylvania Medicaid Provider Enrollment

Aetna

UnitedHealthcare

Cigna Healthcare

Anthem / Elevance Health

Humana

Centene Corporation

Molina Healthcare

Highmark Blue Cross Blue Shield (Western PA)

Independence Blue Cross

Pennsylvania Medical Assistance

UnitedHealthcare Community Plan

Aetna Better Health

AmeriHealth Caritas

TRICARE

TRICARE East Region (Humana Military)

CHAMPVA

Delta Dental

Cigna Dental

MetLife Dental

Guardian Dental

Aetna Dental

United Concordia

DentaQuest

MCNA Dental

Liberty Dental Plan

Dental Network of America

VSP Vision Care

EyeMed Vision Care

Davis Vision

Spectera / UHC Vision

Optum Behavioral Health

Carelon Behavioral Health

Magellan Health

Evernorth Behavioral Health

Clover Health

Devoted Health

Workers' Compensation

Novitas Solutions (Jurisdiction H/L)

Noridian Healthcare Solutions (DME A/D)

Ambetter

AmeriHealth Caritas

Anthem Blue Shield

Blue Cross Blue Shield

Carelon

Centene Corporation

Community Plan

Compsych

Medicaid

Medicare

Medicare Fee-for-Service (CMS)

Megellan

MultiPlan

Oscar

WellCare

Oscar Health

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