The recipient can get medical services from any provider he or she chooses. But DHS will pay only for services from providers who are enrolled in the MA program and who agree to bill DHS.
The CAO must let the recipient know that he or she must get medical services from providers who are enrolled in the MA program. The CAO will use PROMISe to help recipients find a provider. Most hospitals in Pennsylvania accept MA payment.
NOTE: A doctor who gives care at a hospital that is in the program may or may not accept MA payment. The CAO must let the recipient know that he or she will not be paid for payments made or owed to providers who are not in the program.
The recipient must use all available third-party resources to pay medical costs before DHS will pay for a service. The recipient must present other insurance cards as well as the ACCESS card when asking for or getting medical services. (See Appendix H for information about the Eligibility Verification System, which medical providers use to verify client eligibility for medical services.)
The CAO helps recipients find MA providers who accept MA by giving the recipient a list of provider names and addresses. The provider search file in PROMISe lists all providers who are enrolled in the MA program. The CAO can sort the list by ZIP code, county, or specialty to meet the recipient’s needs. (See Appendix C for instructions for using the PROMISe Inquiry System.)
Each CAO will name one worker and an alternate who will help find providers for clients. The MA CARE/PROMISe worker should use the information below.
ACCESS Plus members should call the ACCESS Plus helpline at 1-800-543-7633 for information on providers, including dental providers.
For Mandatory HealthChoices and voluntary managed care:
For an MA recipient enrolled in HealthChoices PH, refer the individual to the right PH managed care organization for information on PH providers, including dental providers.
For an MA recipient enrolled in voluntary PH managed care, refer the individual to the voluntary managed care plan for information on PH providers, including dental providers.
For MA recipients who are enrolled in HealthChoices BH (for example, MA recipients who are eligible for both Medicare and MA), refer the recipient to the BH managed care organization for BH provider information.
For MA recipients who are in the fee-for-service “window” (before the effective date for mandatory or voluntary managed care enrollment), refer the individual to either (a) the MA call center at 1-866-542-3015 for dental provider information or (b) the enrollment broker for other PH providers.
For fee-for-service:
For BH provider information, refer the recipient to the county MH/MR program.
For MA recipients who are not enrolled in either ACCESS Plus or voluntary or mandatory managed care, use MA CARES/PROMISe. The MA CARES/PROMISe worker in the CAO helps these recipients find providers who are in the program, if the recipient asks for help. Do not use MA CARES/PROMISe for dental providers. For dental information, refer the recipient to the MA call center at 1-866-542-3015.
MA recipients sometimes have a copayment for medical services. Certain GA-related recipients have higher copayments than other recipients. (See Appendix D for copayment fees and exclusions.)
NOTE: Services given to recipients who are under 18 years of age, pregnant (including throughout the 12-month postpartum period), or in a nursing home are excluded from copayments.
The provider will tell the recipient the copayment amount and collect that payment. The recipient should request a receipt. MA rules do not allow MA providers to deny a service or item if the recipient cannot make the copayment. The recipient should tell their provider if they cannot afford the copayment amount at the time of service. However, the recipient is still responsible for the copayment, and the provider may try to collect the copayment from the recipient (for example, by billing the recipient for the overdue copayment amount). If the recipient believes that a provider has charged him or her incorrectly for copayments, the recipient must continue to make copayments unless DHS decides that the charges are wrong.
Adult General Assistance MA recipients pay a $150 deductible (the amount the recipient must pay before DHS begins to pay) each fiscal year for the following MA services:
Outpatient surgical center services
Inpatient hospital services
Outpatient hospital services
NOTE: Recipients do not have to pay a deductible for laboratory and x-ray services.
The period for the deductible is from July 1 to June 30 of the following year. Services will be provided even if the recipient cannot pay the deductible.
Certain medical services or items that are covered by the MA program must be approved in advance by the Office of Medical Assistance Programs (OMAP). The service or item must be medically needed and must be ordered or prescribed by a licensed medical provider.
The MA fee schedule is a list of all services and items covered under the MA program. The code "PA" next to a maximum fee means that the service or item must be approved in advance. An item that does not normally need advanced approval will need advanced approval if the total cost is over $100.
Some medical supplies that must be approved in advance may be rented for three months without advance approval. The code "P" on the fee schedule shows that an item must be purchased; "R" means that the item may be rented. The recipient should talk with the prescriber to decide which is better.
NOTE: Each CAO has a copy of the MA fee schedule.
OMAP approves payment for the following:
Narcotic Analgesics
Durable medical equipment costing more than $100, such as a wheelchair or hospital bed.
Rental of durable medical equipment after three months of rental.
Medical and surgical supplies costing more than $100.
Prosthetic or orthotic devices with a "PA" code in the MA fee schedule.
Some dental services, including the following:
Dentures, including partial dentures.
Space maintainers.
Crowns.
Orthodontic service (braces).
Removals of teeth when (a) more than one tooth is removed to put in a prosthetic device or (b) six or more teeth are removed during one visit or period of hospitalization.
Surgical removals of teeth.
Root recovery.
Surgical exposure with approved orthodontics.
Home health Agency Services.
Brand-name drugs used when generic versions are available.
The prescriber requests advanced approval by sending a completed Prior Authorization Request (MA 97), Orthodontic Request (MA 96), or Dental Request (MA 98) directly to OMAP.
NOTE: OMAP gives forms MA 96 and MA 98 to prescribers who use them. The CAO must keep a supply of MA 97 forms to give to other prescribers or to recipients when they ask for them.
Guidelines for emergency approval requests:
The individual asking for the item or service must give a reason why an emergency request is needed and have papers to prove it.
The individual making the request starts by calling the Division of Outpatient Operations at 717-772-6181. After calling, the provider faxes the papers to the Division at 717-772-6331. If the fax is received by noon on the day when emergency approval is requested, the Division will give an answer by the close of that business day. If the fax is received after noon, the Division will give an answer by noon of the next business day.
The individual making the request must fill out and send in a Prior Authorization/1150 Waiver (MA 97). The form includes a page of instructions on how to complete it correctly and the address to send it to.
The MA 97 must reach the office within ten days of the first phone call.
The information given by voice, the fax copy, and the signed hard copy must be the same.
The Division must send a letter confirming the verbal approval to the provider within 21 days after getting the MA 97.
When there is no emergency but a provider needs quicker-than-normal approval to treat a patient, the provider can make an expedited request to speed up the approval process.
Guidelines for expedited requests:
The individual asking for expedited approval must give a reason why an expedited request is needed and have papers to prove it.
The individual making the request starts by calling the Division of Outpatient Operations at 717-772-6181. After calling, the individual must fax a copy of the MA 97 signed by the prescribing doctor along with the papers. The Division must make a decision within three working days after getting the fax.
The individual making the request fills out and sends in a Prior Authorization/1150 Waiver (MA 97). The form includes a page of instructions on how to complete it correctly and the address to send it to.
The MA 97 must reach the office within ten days of the first phone call.
The information given by voice, the fax copy, and the signed hard copy must be the same.
The Division must send a letter confirming the verbal approval to the provider within 21 days after getting the MA 97.
For all advance approval requests, the prescriber and the recipient will get a Prior Authorization Notice (MA 328) approving or denying the request. The recipient may appeal the denial of a medical service. The recipient or the CAO can call OMAP with questions about Advance Approval. (See Appendix J for contact information.)
A recipient who needs an item or service that is not covered by the MA program can turn in an 1150 Administrative Waiver Request Form (MA 325) filled out by the provider. (Administrative waiver requests used to be called program exception requests.)
OMAP may pay for an item or service that is not covered if the following conditions are met:
The recipient is eligible for MA.
The provider is enrolled in the MA program.
Approval of the request is not against state or federal policy or rules.
The MA 325 is completed and signed by the prescribing physician.
The prescribing physician gives OMAP proof that the individual needs the item or service.
NOTE: Prescribers can get MA 325 forms from OMAP.
The Place of Service Review program (PSR) looks at the medical necessity, compensability, and place of a medical procedure before a patient is admitted.
PSR requires a review of:
Elective inpatient admissions to a general hospital.
Elective procedures performed in outpatient surgery centers or hospital short-stay units.
If a PSR is required, the doctor contacts OMAP to find out whether the site for the treatment is approved or another treatment site must be used. OMAP will send the client a notice letting him or her know of the approved treatment site. The site may be different from the one suggested by the doctor, but it will be one with which the doctor is connected.
Example: The PSR could approve a individual’s treatment as an outpatient in a short-stay unit rather than as an inpatient in a hospital.
The Office of Administration (OA) Recipient Restriction (Lock-In) Program may decide that limits must be placed on a recipient’s MA benefits because the individual is misusing or defrauding the MA program.
NOTE: The CAO Executive Director picks a individual to contact OA, Bureau of Program Integrity, when the CAO gets complaints about a recipient’s misuse of the ACCESS card.
When OA finds out that a recipient is misusing MA services, it tells the individual in writing that it plans to limit service and asks the individual to accept a proposed provider or select another provider. If the recipient does not answer within ten days, OA will only allow the recipient to go to the named provider.
Recipient Restriction (Lock-In) Program information is included in EVS. (See Appendix H, Eligibility Verification System.)
NOTE: If the named provider cannot provide a medical service the recipient needs, the provider will make a referral, using a Restricted Recipient Referral form. Providers can get the forms from the OA Restriction Unit.
OA will send the CAO a copy of the letter stating that the recipient’s medical services are limited. OA will send the CAO copies of letters regarding any changes in named providers. The letters are kept in the case record as long as limits continue. The CAO must note "RESTRICTED MA SERVICES" in the case record narrative (CIS case comments) and on the face of the case record folder.
If the recipient requests a different provider, the CAO will contact the Recipient Restriction Unit for approval. All inquiries, requests, or complaints from providers, recipients, and the general public must go to:
Bureau
of Program Integrity,
Division of Program and Provider Compliance, Recipient Restriction
Unit
The phone number is (local) (717) 772-4627 or toll free at 866-400-5843.
CIS has a code for limits on service (“Lock-In”).
In some counties, recipients are enrolled in a managed care organization (MCO). A recipient in an MCO goes to a primary care physician, who is responsible for managing the recipient’s medical care. Each month, the DHS pays the MCO a set amount for each individual in the MCO. Under DHS rules, MCOs must provide the same medical coverage that is available to recipients under the fee-for-service Healthcare Benefits Package.
NOTE: An unemancipated child cannot sign an MCO enrollment form. The form is signed by a parent or another adult in charge of the child.
When a recipient enrolls in an MCO, he or she gets a medical services ID card from the plan and an ACCESS card from DHS. The ACCESS card identifies the recipient for the Medical Assistance Transportation Program (MATP).
The Enrollment Assistant Program (EAP) contractor or someone who handles managed care assists the recipient in selecting a managed care plan. When a recipient enrolls in or leaves a managed care program, that information is automatically posted to CIS. Valid managed care plans are listed in the Systems Reference THMO table in CIS.
Enrollment in an MCO is not available for recipients who are in any of the following situations or programs:
A noncontinuous eligibility (NCE) period.
Exception: Newborns are enrolled in the mother’s MCO.
NMP Spend-down, if a monthly review of eligibility is required.
A nursing home or other facilities.
NOTE: Special rules apply when a facility code is entered in CIS. For information about facility codes, go to the OIM Intranet Home page. Click on Health Choices Information. Under General Information on the left, click on codes. Then click on facility placement codes.
Healthy Horizons Cost-Sharing PG.
Healthy Beginnings Presumptive Eligibility PS-17.
Specified Low Income Medicare Beneficiaries (SLMB) TA/TJ 65.
Qualifying Individuals (QI-1 Buy In) TA/TJ 67.
State Blind Pension and TB.
Breast and Cervical Cancer Prevention and Treatment (BCCPT) PH/20.
CIS sets the MCO begin date.
If a budget is closed and reopened within six months, CIS re-enrolls the budget in the MCO. The recipient can choose another provider when the budget is reopened.
NOTE: If the recipient’s MCO fee is paid by an employer, a court order, or any other third party, the MCO resources must be processed as other third-party resources.
The CAO will enter code 7 on the “Individual Action” screen in CIS.
The CAO will enter the information for the MCO into the TPL Master File. (See “Using TPL.”)
The recipient may use MA for medical services from an out-of-state provider if:
The recipient needs emergency medical care while temporarily away from home.
The recipient would be risking his or her health by waiting for the service until returning home.
The trip back to Pennsylvania would endanger the recipient’s health.
It is general practice for recipients in that area of the state to use medical resources in a neighboring state.
DHS decides, on the attending practitioner’s advice, that the recipient has better access to the needed care in another state.
OMAP decides whether DHS will pay for the service. If the provider is not familiar with DHS’s billing process, the CAO refers the provider to OMAP. The provider can get information on the Internet at
The CAO must submit bills or invoices from out-of-state providers to the following address: services.dpw.state.pa.us.
Department of Human Services
Office of Medical Assistance Programs
P.O. Box 8050
Harrisburg, PA 17105-8050
NOTE: Out-of-state providers must enroll with OMAP to receive payment.
The CAO will attach a memo giving the following information:
The name of the out-of-state provider.
The name and case number of the recipient.
The name of the CAO.
The name of the CAO worker to contact if there are any questions.
Updated September 19, 2023, Replacing December 2, 2013