Pennsylvania Medicaid — Pennsylvania Medical Assistance (HealthChoices)
| Program name | Pennsylvania Medical Assistance (HealthChoices) |
|---|---|
| Provider portal | https://www.dhs.pa.gov/providers |
| FFS claims payer ID | No single canonical ID — routing is fiscal-intermediary-specific. Verify per clearinghouse. |
| Medicaid timely filing | 180 days from date of service |
The federal ceiling for Medicaid timely filing is 12 months under 42 CFR §447.45; most states set a shorter window. Always verify the current policy on the Pennsylvania Medicaid provider portal before filing a late-billing appeal.
BCBS licensee in Pennsylvania
The Blue Cross Blue Shield Association licensee in Pennsylvania is Independence Blue Cross (Philadelphia region) / Highmark BCBS (West). See the Independence Blue Cross payer guide for payer ID, timely filing, prior auth, and appeal procedures.
Top commercial payers in Pennsylvania
The dominant commercial insurers operating in Pennsylvania, in approximate order of lives covered. Click through for per-payer claims payer IDs, timely filing windows, prior-authorization rules, and appeal procedures.
Medicaid MCOs in Pennsylvania
Pennsylvania Medical Assistance (HealthChoices) contracts with the following managed-care organizations to administer Medicaid benefits in Pennsylvania. MCO contracts dictate claims routing, prior-auth workflows, and appeal deadlines — route each claim by the member's MCO assignment, not the state FFS payer ID.
Medicare contractor and active LCDs in Pennsylvania
Novitas Solutions, Inc. is the Medicare A/B MAC for Pennsylvania: Part A and Part B fee-for-service claims from Pennsylvania go to it, and its Local Coverage Determinations decide local medical necessity. Durable medical equipment and supply claims go to Noridian Healthcare Solutions, LLC as the DME MAC. Home health and hospice claims are processed by CGS Administrators, LLC. In the current Medicare Coverage Database export, 130 active LCDs from these contractors apply to Pennsylvania claims.
- Novitas Solutions, Inc.
A/B MAC (Part A and Part B claims)
- Noridian Healthcare Solutions, LLC
DME MAC (durable medical equipment and supplies)
- CGS Administrators, LLC
Home health and hospice MAC
Selected active Novitas Solutions, Inc. policies for Pennsylvania
A selection, not the full list: policies with measured search demand come first, then those on topics that more contractors publish LCDs for.
- L35041 Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds
- L34892 Facet Joint Interventions for Pain Management
- L36920 Epidural Steroid Injections for Pain Management
- L39365 Genetic Testing in Oncology: Specific Tests
- L34914 Assays for Vitamins and Metabolic Function
- L35396 Biomarkers for Oncology
- L35010 Trigger Point Injections
- L35038 Scanning Computerized Ophthalmic Diagnostic Imaging
- L34938 Removal of Benign Skin Lesions
- L35138 Routine Foot Care
- L38916 Respiratory Pathogen Panel Testing
- L35006 Controlled Substance Monitoring and Drugs of Abuse Testing
Equipment, home health and hospice policies that apply in Pennsylvania
- L33822 Glucose Monitors
- L33789 Power Mobility Devices
- L33318 Knee Orthoses
- L33686 Ankle-Foot/Knee-Ankle-Foot Orthosis
- L33718 Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea
- L33792 Wheelchair Options/Accessories
- L33797 Oxygen and Oxygen Equipment
- L33942 Physical Therapy - Home Health
Steps to confirm which LCD governs a claim · Every active LCD by contractor
State-specific regulations affecting Pennsylvania billing
- PA Act 146 of 2020 (Surprise Balance Billing protections)
- 40 P.S. §991.2166 / Act 68 (prompt pay and claim disputes for HMOs)
- PA Act 6 of 1993 / HMO prompt payment — 45 days clean claim
Provider licensing & enrollment in Pennsylvania
Providers enroll with PA MA via PROMISe Provider Portal. Each HealthChoices MCO contracts separately. PA requires MA enrollment to bill any HealthChoices MCO.
Major health systems headquartered in Pennsylvania
| Health system | Headquarters |
|---|---|
| UPMC | Pittsburgh, PA |
| Penn Medicine (University of Pennsylvania Health System) | Philadelphia, PA |
| Geisinger | Danville, PA |
| Jefferson Health | Philadelphia, PA |
| Main Line Health | Radnor, PA |
Frequently asked questions — Pennsylvania billing
What is the Pennsylvania Medicaid program called?
Pennsylvania's Medicaid program is known as Pennsylvania Medical Assistance (HealthChoices). Providers enroll and manage claims through the provider portal at https://www.dhs.pa.gov/providers.
What is the Pennsylvania Medicaid timely filing limit?
Pennsylvania Medical Assistance (HealthChoices) requires initial claims to be filed within 180 days from the date of service. The federal ceiling is 12 months under 42 CFR §447.45; Pennsylvania's 180-day window is set by the state provider manual. Late-billing exceptions may be allowed with good-cause documentation — verify on the state portal before filing an appeal.
Does Pennsylvania Medicaid publish a single claims payer ID?
No single canonical claims payer ID is published for Pennsylvania Medical Assistance (HealthChoices). Claims route through the state's fiscal intermediary; look up the correct submitter ID in your clearinghouse directory (Availity, Change Healthcare/Optum, Waystar) and route managed-care claims by the member's MCO assignment.
Who are the largest commercial insurers in Pennsylvania?
The dominant commercial payers in Pennsylvania include Independence Blue Cross, Highmark BCBS, UnitedHealthcare, Aetna, Cigna, along with the BCBS licensee Independence Blue Cross (Philadelphia region) / Highmark BCBS (West). Each payer's claims routing, timely filing, and prior-auth rules differ — see the per-payer guides linked above.
What Medicaid managed-care organizations operate in Pennsylvania?
Pennsylvania Medical Assistance (HealthChoices) contracts with 2 Medicaid MCOs tracked in the QuickIntell registry, including UnitedHealthcare, Aetna. MCO contracts determine claims routing and appeal deadlines — route each claim by the member's MCO assignment, not by the FFS payer ID.
What state-specific billing regulations apply in Pennsylvania?
Pennsylvania has 3 tracked state-level statutes that affect medical billing and RCM: PA Act 146 of 2020 (Surprise Balance Billing protections); 40 P.S. §991.2166 / Act 68 (prompt pay and claim disputes for HMOs); PA Act 6 of 1993 / HMO prompt payment — 45 days clean claim. These sit on top of federal protections such as the No Surprises Act, HIPAA, and 42 CFR §447.45.
Run cleaner claims in Pennsylvania with QuickIntell
QuickRCM, QuickAuth, and QuickERA are tuned to Pennsylvania Medical Assistance (HealthChoices) and the commercial payers on this page — eligibility, prior auth, claim scrubbing, and ERA posting all run on real payer rules, not generic adapters.
Disclaimer
This page is operational reference for medical-billing professionals. It is not legal, clinical, or contractual advice. State Medicaid policies, MCO contracts, and payer rules change without notice — always verify against the current provider manual from Pennsylvania Medicaid and the member ID card before submission.