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Pennsylvania - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Pennsylvania, Case Management for Medicaid Home and Community-Based Services (HCBS) is primarily referred to as Service Coordination. This service involves comprehensive assessment, person-centered service plan development, referral, and ongoing monitoring of a participant's full service package. The service is administered primarily through two divisions of the Department of Human Services (DHS): the Office of Developmental Programs (ODP) for individuals with intellectual disabilities and autism, and the Office of Long-Term Living (OLTL) for aging individuals and those with physical disabilities.

The single biggest structural barrier to entry for this service in Pennsylvania is the strict enforcement of Conflict-Free Case Management (CFCM) combined with Managed Care network restrictions. Under ODP, an agency is structurally barred from enrolling if it intends to provide both direct HCBS waiver services and Service Coordination to the same individuals. Under OLTL's Community HealthChoices (CHC) program, enrolling with the state is not enough; providers face a closed-network managed care gate and must secure contracts with specific regional Managed Care Organizations (MCOs) to receive referrals and bill for services.

1. Service Definition and Scope

Pennsylvania defines this service as Service Coordination under its HCBS waivers and Targeted Case Management (TCM) under the Medicaid State Plan. The core function is to assist participants in gaining access to needed waiver services, Medicaid State Plan services, and other medical, social, and educational services regardless of the funding source.

Service Coordinators are responsible for facilitating the person-centered planning process, developing the Individual Support Plan (ISP) or Person-Centered Service Plan (PCSP), and conducting ongoing monitoring to ensure services are delivered in accordance with the plan and the CMS HCBS Settings Rule.

2. Regulatory and Oversight Agencies

The Pennsylvania Department of Human Services (DHS) is the single state Medicaid agency responsible for all HCBS programs. Oversight is bifurcated based on the target population served by the specific waiver.

ODP manages the intellectual disability and autism waivers, while OLTL manages the aging and physical disability waivers, primarily through the Community HealthChoices (CHC) managed care model.

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania does not require a Certificate of Need for case management, but it enforces severe structural preconditions before an application is accepted. Providers must clear specific programmatic gates depending on whether they are applying under ODP or OLTL.

For ODP, the state enforces a strict orientation and qualification timeline. For OLTL, the transition to Managed Long-Term Services and Supports (MLTSS) means that state enrollment is entirely subordinate to MCO network contracting.

4. Licensure and Certification Requirements

Pennsylvania does not issue a traditional facility or agency license for Case Management or Service Coordination through the DHS Bureau of Human Services Licensing. There is no specific PA Code licensing chapter (like Chapter 6400 for group homes) that applies to this service.

Instead, agencies must achieve "Provider Qualification" status directly from the operating program office (ODP or OLTL). This process acts as the functional equivalent of licensure, requiring the submission of policies, procedures, and organizational charts to prove capability.

5. Medicaid Provider Enrollment

Once Provider Qualification is achieved through ODP or OLTL, the agency must enroll in the Pennsylvania Medical Assistance program. This is done electronically through the PROMISe (Provider Reimbursement and Operations Management Information System) portal.

Providers must select the correct Provider Type and Specialty codes that correspond to Service Coordination for their specific target population, and upload their qualification approvals as attachments.

6. Staffing, Training and Background Checks

Staffing qualifications for Service Coordinators are strictly defined in the approved 1915(c) waiver appendices and 55 Pa. Code Chapter 1247. Agencies must ensure all staff meet educational minimums before they bill for any services.

Pennsylvania also enforces strict background check requirements, including state and federal criminal history clearances and child abuse clearances where applicable.

7. Documentation, Policies and Records

Service Coordination agencies must maintain comprehensive records that prove active, ongoing monitoring of the participant's health, safety, and service delivery. The Individual Support Plan (ISP) is the central governing document.

The state requires specific frequencies for face-to-face and telephone contacts, and all interactions must be documented in the state's designated IT systems.

8. Billing, Rates and Claims

Billing mechanisms in Pennsylvania depend entirely on the waiver program. ODP waiver claims are submitted directly to the state's MMIS (Fee-for-Service), while OLTL CHC claims must be submitted to the contracted Managed Care Organization.

Rates for ODP Service Coordination are standardized and published annually by DHS, whereas CHC rates may be negotiated with the MCOs, though they often mirror the state fee schedule.

9. Approval Sequence and Timeline

The end-to-end process for becoming a Service Coordination provider in Pennsylvania can take 4 to 8 months. The timeline is heavily dependent on the provider's speed in completing the mandatory orientation and the state's processing volume.

For OLTL providers, the timeline is extended by the MCO credentialing process, which cannot begin until the PROMISe enrollment is fully approved.

10. Common Denials and Survey Findings

Applications are frequently rejected at the front door for administrative errors, missed deadlines, or failure to meet the strict Conflict-Free Case Management standards. DHS is rigid regarding the 120-day orientation window.

Post-enrollment, the Quality Management Enterprise Team (QMET) monitors compliance. Citations frequently involve failures in documentation or missed monitoring visits.

11. Key Contacts and Resources

Providers should rely on the official DHS portals and program office websites for the most current manuals, fee schedules, and enrollment forms. The MyODP portal is essential for ID/A providers.

For OLTL providers, direct communication with the Provider Network Management departments of the CHC MCOs is required for contracting.

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