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DHS Requirement Regarding CHIP Enrollment

We want to remind providers that effective January 1, 2018, the Pennsylvania Department of Human Services (DHS) will be implementing a provision of the Affordable Care Act (ACA)1 that will require all providers who order, refer, prescribe or render items or services to Children’s Health Insurance Program (CHIP) enrollees be enrolled with DHS.

Providers must submit a completed enrollment application to DHS for their specific provider type for each service location. These documents should be received by DHS at least 60 days in advance of the deadline to allow for timely processing of the application. Providers may receive reminders from multiple CHIP managed care organizations (MCOs) but are only required to enroll once.

  • Providers must submit their application and related documents as soon as possible in order to meet the January 1 deadline.
  • If a provider has already submitted an application to be enrolled in the Pennsylvania Medical Assistance (MA) Program, then the provider does notneed to enroll again.
  • Even if a provider is a part of another state’s Medicaid or CHIP program — or enrolled in Medicare — providers will still be required to enroll in Pennsylvania.
  • A separate enrollment is required for each provider practice location.

CHIP Provider Application Details

To start the application process, providers must select a provider type that is based on their current scope of practice. All applications, requirements and the step-by-step instructions are available on the following website: http://dhs.pa.gov/provider/promise/enrollmentinformation/CHIPProEnrollInfo/
index.htm
.

Providers are required to complete one of the following applications:

  • CHIP Individual Practitioner Enrollment Application
  • CHIP Provider Facility/Agency Enrollment Application
  • CHIP Provider Group Enrollment Application

Providers should ensure that the application is completed in full and the information is accurate to avoid any delays in processing. If you have any questions regarding the application, please contact Provider Enrollment at 1-800-537-8862.

The current methodology regarding claims processing will not change. The applicable CHIP MCO will provide claims adjudication for all services rendered by a CHIP provider. However, effective January 1, 2018, any claims submitted to a CHIP MCO by a non-enrolled provider will not be paid.

Send the completed application to:

DHS Provider Enrollment

PO Box 8045

Harrisburg, PA 17105-8045

Fax: (717) 265-8284

E-mail: Ra-ProvApp@pa.gov

1 The Patient Protection and Affordable Care Act (Pub. L. 111-148, enacted on March 23, 2010), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152, enacted on March 30, 2010), is being collectively referred to in this document as the Affordable Care Act.

Please note: Section 6401(b) of the ACA amended section 1902 of the Social Security Act (“Act”) to add subsections (a)(77) and (kk), which include requirements for provider enrollment and screening. Additionally, Section 1866(j)(1)(A) of the Act requires the Secretary of U.S. Department of Health and Human Services (HHS) to determine the level of screening of providers to be conducted according to the risk of fraud, waste, and abuse assigned to the category of the provider. The HHS regulations implementing these requirements can be found at 42 CFR Part 455, subpart E.

Section6401(c) of the ACA amends Section 2107(e)(1) of the Act by mandating that subsections (a)(77) and (kk) of Section 1902 of Title XIX of the Act shall apply to States in the same manner under Title XXI of the Act.

 

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