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Medical Billing Services in Pennsylvania

Pennsylvania's Medicaid program is called Medical Assistance, and it reaches most practices through two managed care programs: Physical HealthChoices, and Community HealthChoices for older and dual-eligible adults. Commercial claims fall under a state prompt-payment regulation, and workers' comp and auto injuries each have their own medical payment rules. We bill remotely for Pennsylvania practices.

  • Physical HealthChoices and Community HealthChoices plan claims
  • Clean commercial claims followed up under the state prompt-pay regulation
  • Workers' comp priced to the state fee schedules
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Medical Assistance: Physical HealthChoices and Community HealthChoices

Physical HealthChoices is the managed care program that Pennsylvania Medical Assistance recipients are required to join, with care delivered by physical health managed care organizations.

Community HealthChoices coordinates coverage for adults 21 and older who receive both Medicare and Medicaid, or who receive Medicaid long-term services and supports. Dual-eligible patients in that program need both their Medicare coverage and their CHC plan identified on every claim.

Official sources: PA Department of Human Services: Physical HealthChoices (external site), PA Department of Human Services: Community HealthChoices (external site)

Payment rules set in Pennsylvania regulation

Two state rule sets shape how quickly and how much Pennsylvania practices are paid.

  • Prompt payment of clean claims

    Under 31 Pa. Code § 154.18, licensed insurers and managed care plans must pay clean claims within the period the regulation sets, and providers can file prompt-pay complaints with the Insurance Department.

  • Maximum fees for injured workers' care

    The Department of Labor and Industry publishes fee schedules that set the maximum fees allowed for medical services to injured workers.

Official sources: 31 Pa. Code § 154.18: prompt payment (external site), PA Department of Labor and Industry: workers' compensation fee schedule (external site)

How remote billing works for practices in Pennsylvania

Everything is handled from outside the practice, through your practice management system and the HealthChoices and commercial plan portals. Your practice issues our logins and can withdraw them whenever it chooses.

  1. Step 1: Separate HealthChoices from CHC

    Medical Assistance patients are matched to their Physical HealthChoices or Community HealthChoices plan before the visit.

  2. Step 2: Track the prompt-pay clock

    Clean commercial claims are monitored against the prompt-payment regulation, and overdue claims are escalated.

  3. Step 3: Check work-injury bills against state maximums

    Workers' comp bills are compared with the maximum fees in the Department of Labor and Industry's current schedules.

  4. Step 4: Bill accident care to Medical Benefits

    Auto injury visits are billed to the patient's auto Medical Benefits coverage first.

Practices we typically see in Pennsylvania

Pennsylvania practices typically bill Novitas Solutions for traditional Medicare, Physical HealthChoices managed care organizations for most Medical Assistance patients, and Community HealthChoices plans for dual-eligible and long-term-care patients.

Who oversees what in Pennsylvania

The Pennsylvania Insurance Department oversees health insurers and commercial health insurance products, while the Department of Human Services oversees most Medical Assistance functions. Knowing which agency oversees the patient's coverage decides where an unresolved issue is escalated.

Auto insurance in Pennsylvania must include Medical Benefits coverage, which pays covered people's accident medical bills regardless of fault. Accident visits are billed to that coverage under the policy's terms, which we confirm for each case.

Official sources: Pennsylvania Insurance Department: health coverage annual report (external site), Pennsylvania Insurance Department: auto insurance guide (external site)

Official sources for Pennsylvania

Rules change. These are the agencies and contractors we check for the current requirements.

Frequently asked questions

Where do Pennsylvania practices send traditional Medicare claims?

Novitas Solutions, the Medicare Administrative Contractor for Jurisdiction L, which also covers New Jersey, Delaware, Maryland and the District of Columbia.

Official source: CMS: A/B MAC Jurisdiction L (Novitas Solutions) (external site)

What is Community HealthChoices?

The Department of Human Services program for adults 21 and older who have both Medicare and Medicaid, or who receive Medicaid long-term services and supports.

Official source: PA Department of Human Services: Community HealthChoices (external site)

What can we do when a Pennsylvania insurer pays a clean claim late?

31 Pa. Code § 154.18 requires prompt payment of clean claims by licensed insurers and managed care plans, and providers can file a prompt-pay complaint with the Insurance Department.

Official source: 31 Pa. Code § 154.18: prompt payment (external site)

How is workers' comp care priced in Pennsylvania?

Against fee schedules published by the Department of Labor and Industry, which set the maximum fees allowed. We price each bill against the current schedule.

Official source: PA Department of Labor and Industry: workers' compensation fee schedule (external site)

Can a remote team manage HealthChoices plan billing?

Yes. HealthChoices and CHC plan claims and portals are electronic. We bill them remotely for practices anywhere in the state.

Related services and nearby states

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See where Pennsylvania claims are slowing down

A free audit shows late-paid clean claims, HealthChoices and CHC denials, and workers' comp pricing issues.

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