In order for providers to participate with the Department of Human Services, they must first enroll. Enrollment Information. Beginning on August 1, 2018, the provider may have to call the Office of Medical Assistance Programs, Provider Enrollment at 1-800-537-8862 to request a paper application if the PDF version of the application is no longer posted on the DHS Provider Enrollment website.

Pennsylvania PROMISe™ Provider Handbook 837 Institutional/UB-04 Claim Form September 2015, Version 2.18 In order for providers to participate with the Department of Human Services (DHS), they must first enroll.

If you have more than 4 taxonomy system documentation library reference number: [00000164] section: 4-5b library reference number: [0000082] provider internet user manual CHIP Provider Enrollment Information. If you are reactivating a provider number, indicate the PROMISe™ 13 digit provider number you wish to have reactivated and complete the application as an initial enrollment. The table below contains links to applicable provider enrollment forms for each provider type. Quick Tip 240 - Provider enrollment and revalidation changes during the COVID-19 emergency Quick Tip 241 - Prior Authorization Changes in the Medical Assistance Program for Certain Services during COVID-19 Emergency Disaster Quick Tip 242 - Telemedicine Guidelines Related to COVID-19 3. 2c. If you are reactivating a provider number, indicate the PROMISe™ 13 digit provider number you wish to have reactivated and complete the application as an initial enrollment. PROMISe™ Provider Enrollment !pplication and any required forms; This form cannot be used to add a service location where actual recipient services are rendere. Provider Enrollment Documents. 2c. If additional changes are required, copy pages 2 and 3 or attach sheets using identical format. INSTRUCTIONS FOR COMPLETION OF PENNSYLVANIA PROMISe™ PROVIDER ENROLLMENT BASE APPLICATION Applications must be typed or completed in black ink, or they will not be accepted. 3. Welcome to the Pennsylvania (PA) Department of Human Services (DHS) Medical Assistance (MA) and Children's Health Insurance Program (CHIP) On-line Provider Enrollment Application. To be eligible to enroll, practitioners in Pennsylvania must be licensed and currently registered by the appropriate state agency. 1. The Department of Human Services (Department) is implementing the Affordable Care Act (ACA) Provider Screening and Enrollment provisions which require all providers who render services to CHIP enrollees to … Note: Out‐of‐State providers must submit proof of participation in your State’s Medicaid Program. pa promise™ provider internet user manual . If you have more than 4 taxonomy Enter your National Provider Identifier (NPI) Number and taxonomy(s). INSTRUCTIONS FOR COMPLETION OF PENNSYLVANIA PROMISe™ PROVIDER ENROLLMENT FACILITY/AGENCY APPLICATION Table of Contents Instructions 1-3 Facility/Agency Application 4-8 Provider Agreement 9-10 Provider Disclosure Form 11-20 Application Checklist 21 Instructions 1. Enter your National Provider Identifier (NPI) Number and taxonomy(s).