2c. PROMISe™ ID ENROLLMENT FOR CHIP .

Select the Provider Type (required) and the Specialty (optional) . This window is accessed from the PA PROMISe™ Internet Provider My Home Page and clicking on the EFT and ERA Enrollment Alternate accounts can be authorized by a provider to bill for more than one 13-digit MPI and Service Location. Check if this is a revalidation. Select/Enter values in at least two of the three sections below to initiate search. To enroll, providers must complete a Base Provider Enrollment form and any applicable addenda documents dependent on the provider type. To enroll, providers can complete an on-line provider enrollment application and supply any required supporting documentation. 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. Providers, included in the online PROMISe™ Provider Enrollment Base Application. 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.

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 … Electronic Remittance Advice (ERA) Enrollment Application Window. Note: Out‐of‐State providers must submit proof of participation in your State’s Medicaid Program. This includes providers who are not billing PA Medicaid or CHIP but provide services to beneficiaries. Pennsylvania's Department of Public Welfare's (DPW's) claim processing and management information system provided by Hewlett Packard's Enterprise Services stands for Provider Reimbursement and Operations Management Information System (in electronic format). PROMISe . 2a. Internet Portal, email promise@pa.gov, or call the Provider Enrollment Hotline at 1-800-537-8862, and select options 2, option 4, and finally option 2 to speak to a representative. Pennsylvania’s Promise for Children, known as PA Promise, is a campaign to help families make good choices about their child’s early learning and choose quality early learning programs that are right for their family. Again, it is often easier for us to research your specific problem if you write us. Check if this is the initial enrollment. To be eligible to enroll, practitioners in Pennsylvania must be licensed and currently registered by the appropriate state agency. pa promise™ provider internet user manual . FAQs ABOUT PROVIDER PROMISe ID ENROLLMENT, REVALIDATION AND ORDERING, REFERRING, PRESCRIBING (ORP) ENROLLMENT PROCESSES .


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