CASE MANAGEMENT SERVICES PROVIDER IN PENNSYLVANIA

Fatumata Kaba
Oct 8
4 min read

COORDINATING CARE, SERVICES, AND SUPPORTS TO HELP INDIVIDUALS NAVIGATE MEDICAID SYSTEMS AND LIVE SAFELY IN THEIR COMMUNITIES

Case Management Services in Pennsylvania are Medicaid-funded supports that assist individuals with disabilities, chronic illnesses, or aging-related needs in accessing and coordinating the full range of Home and Community-Based Services (HCBS). Case managers (also known as Service Coordinators or Supports Coordinators) develop service plans, monitor care delivery, and connect individuals with waiver services to improve quality of life and prevent institutionalization. These services are delivered under the Office of Long-Term Living (OLTL), Office of Developmental Programs (ODP), and Community HealthChoices (CHC) Managed Care Organizations (MCOs).

1. GOVERNING AGENCIES

Agency: Pennsylvania Department of Human Services (DHS) – OLTL & ODP

Role: Establishes standards, monitors performance, and funds case management services under HCBS waivers.

Agency: Community HealthChoices (CHC) Managed Care Organizations (MCOs)

Role: Contract with Service Coordination Entities (SCEs) to manage long-term supports for CHC members.

Agency: Centers for Medicare & Medicaid Services (CMS)**

Role: Oversees federal requirements for HCBS care coordination under 1915(c) and MLTSS programs.

Agency: Pennsylvania Department of State

Role: Handles business registration for provider entities delivering case management.

2. CASE MANAGEMENT SERVICES OVERVIEW

Case Management (also referred to as Supports Coordination or Service Coordination) includes comprehensive planning, facilitation, and oversight of all waiver services for eligible individuals.

Approved providers may deliver:

Comprehensive Assessments: Evaluating functional needs, strengths, risks, and preferences.
Service Planning: Developing, revising, and implementing Individual Support Plans (ISP) or Person-Centered Service Plans (PCSP).
Coordination & Referrals: Connecting individuals with housing, medical, behavioral, transportation, and social services.
Monitoring & Follow-Up: Ensuring timely service delivery, health and safety oversight, and plan compliance.
Crisis Intervention: Addressing emergent issues and coordinating supports during hospitalization or service interruption.
Documentation: Case notes, contact logs, ISP updates, critical incident reports, and Medicaid billing records.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

Register your entity with the Pennsylvania Department of State.
Obtain an EIN and a Type 2 NPI.
Enroll with PROMISe™ as a Service Coordination Entity (SCE) or Supports Coordination Organization (SCO).
Contract with CHC MCOs (UPMC, PA Health & Wellness, Keystone First), ODP Administrative Entities, or OLTL waiver programs.
Maintain general liability, professional liability, and workers’ compensation insurance.
Develop a Case Management Services Policy & Procedure Manual consistent with DHS and CMS care coordination standards.

4. PENNSYLVANIA PROVIDER ENROLLMENT PROCESS

Step 1: Register your business and obtain EIN, NPI, and insurances.

Step 2: Submit provider qualification application through the HCSIS portal (ODP) or via CHC/OLTL pathways.

Step 3: Upload staffing plan, credentials, supervision protocols, and policies.

Step 4: Complete contracting and onboarding with MCOs or Administrative Entities.

Step 5: Begin receiving referrals and authorizations to conduct assessments and coordinate services.

5. REQUIRED DOCUMENTATION

Business registration and Articles of Incorporation
EIN and NPI confirmation
Insurance certificates (liability, professional, workers’ comp)
Case Management Policy & Procedure Manual including:
- Intake, eligibility screening, and risk assessment procedures
- Plan development and service authorization processes
- Monitoring and follow-up protocols
- Critical incident management and escalation procedures
- Participant rights and informed choice guidelines
- Documentation standards and visit note templates
- Compliance logs and Medicaid billing formats
- Staff training, supervision, and performance review policies

6. STAFFING REQUIREMENTS

Role: Supports/Service Coordinator

Requirements: Bachelor’s degree in social work, human services, or related field; knowledge of HCBS services; strong documentation and advocacy skills.

Role: Supervisor / Program Manager

Requirements: At least 2 years of relevant experience plus supervisory training; oversees caseloads and quality control.

Role: Intake Specialist (optional)

Requirements: Manages referrals, screening, and eligibility documentation.

All staff must complete:

Mandatory Reporter and abuse prevention training
HIPAA and participant rights modules
ISP/PCSP development and documentation training
Crisis response and incident management protocols
Annual refresher courses and performance evaluations

7. MEDICAID WAIVER PROGRAMS

Case Management Services are available through:

Community HealthChoices (CHC):
- Managed care model for adults 21+ needing long-term services
Independence, OBRA, and Aging Waivers (OLTL):
- OLTL authorizes case management for Medicaid-eligible adults with functional impairments
ODP Waivers (Consolidated, Community Living, P/FDS):
- Supports Coordination provided by ODP-approved agencies
Act 150 Program (non-Medicaid):
- State-funded case management for adults not yet MA-eligible

8. TIMELINE TO LAUNCH

Phase: Business Registration & Manual Development

Timeline: 1–2 months

Phase: Provider Enrollment & Contracting

Timeline: 2–3 months

Phase: Staff Hiring, Credentialing & Training

Timeline: 30–60 days

Phase: Referral Activation & Caseload Assignment

Timeline: Begins upon approval and onboarding with AE or CHC MCO

9. CONTACT INFORMATION

PA DHS – Office of Long-Term Living (OLTL)

Website: https://www.dhs.pa.gov

PA DHS – Office of Developmental Programs (ODP)

Website: https://www.myodp.org

HCSIS Provider Portal (ODP)

Website: https://www.hcsis.state.pa.us

PROMISe™ Medicaid Provider Portal

Website: https://promise.dpw.state.pa.us

Community HealthChoices MCOs:

UPMC CHC – https://www.upmchealthplan.com
Keystone First CHC – https://www.keystonefirstchc.com
PA Health & Wellness – https://www.pahealthwellness.com

Centers for Medicare & Medicaid Services (CMS)

Website: https://www.cms.gov

WAIVER CONSULTING GROUP’S START-UP ASSISTANCE SERVICE — PENNSYLVANIA CASE MANAGEMENT PROVIDER

WCG supports new Service Coordination and Supports Coordination agencies in Pennsylvania by equipping them with tools to deliver compliant, person-centered case management services.

Scope of Work: