Waiver Consulting Group — Start any program. In any state.

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

Last reviewed: 2026-09-10

The Pennsylvania Department of Human Services (DHS) funds case management through its Medicaid waivers under the title Supports Coordination, requiring prospective agencies to pass the Office of Developmental Programs (ODP) or Office of Long-Term Living (OLTL) Provider Qualification process before applying for Medicaid enrollment. Pennsylvania does not issue a traditional facility or agency license for this service; instead, operating authority is granted through waiver-specific qualification and subsequent enrollment in the Provider Reimbursement and Operations Management Information System (PROMISe).

For providers targeting the aging and physical disability populations under OLTL, the structural precondition is securing network contracts with the Community HealthChoices (CHC) Managed Care Organizations (MCOs), which frequently close their networks based on regional adequacy. For intellectual and developmental disability populations under ODP, providers must secure an operating agreement with a county Administrative Entity (AE) after completing the state's mandatory New Provider Orientation and qualification packet.

1. Service Definition and Scope

In Pennsylvania, Medicaid HCBS case management is officially designated as Supports Coordination or Targeted Support Management (TSM). This service involves locating, coordinating, and monitoring services and supports for waiver participants to ensure their health, safety, and welfare.

Supports Coordinators (SCs) are responsible for conducting needs assessments, developing the Individual Support Plan (ISP) or Person-Centered Service Plan (PCSP), and performing ongoing monitoring through face-to-face and telephonic contacts. The service spans multiple waivers, including the Consolidated, Community Living, and Person/Family Directed Support (P/FDS) waivers under ODP, and the Community HealthChoices (CHC) waiver under OLTL.

2. Regulatory and Oversight Agencies

The Pennsylvania Department of Human Services (DHS) is the single state Medicaid agency responsible for overall program administration. Within DHS, specific program offices manage the waivers and oversee Supports Coordination Organizations based on the target population.

The Office of Developmental Programs (ODP) oversees SCOs serving the ID/A populations, while the Office of Long-Term Living (OLTL) oversees those serving aging and physically disabled populations. Medicaid enrollment and claims processing are managed through the PROMISe system.

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania does not utilize a Certificate of Need (CON) program for Supports Coordination, but it enforces strict structural prerequisites before a PROMISe enrollment application is accepted. For ODP waivers, an applicant must first complete the ODP New Provider Orientation and submit a New Provider Qualification packet; PROMISe will reject applications lacking the ODP approval letter.

For OLTL waivers operating under the Community HealthChoices (CHC) managed care model, PROMISe enrollment alone does not guarantee the ability to bill. Providers must secure credentialing and contracts with the designated CHC-MCOs (e.g., UPMC, PA Health & Wellness, AmeriHealth Caritas), which frequently enforce closed networks due to network adequacy standards.

4. Licensure and Certification Requirements

Pennsylvania does not license Supports Coordination Organizations under a distinct facility or agency licensure authority. Instead, providers are approved through a certification and qualification process governed by state regulations.

ODP providers must comply with 55 Pa. Code Chapter 51 (Office of Developmental Programs Home and Community-Based Services). OLTL providers must comply with 55 Pa. Code Chapter 52 (Long-Term Living Home and Community-Based Services). Compliance is verified through the initial qualification application and subsequent state or MCO audits.

5. Medicaid Provider Enrollment

Once the prerequisite qualification is obtained, the agency must enroll as a billing provider through the PROMISe Provider Portal. The application requires the submission of the qualification letter, ownership disclosures, and an active National Provider Identifier (NPI).

Upon initiating a new application in PROMISe, the system generates an Application Tracking Number (ATN). Providers must retain this ATN to track their application status, as the portal does not allow users to save and return to an incomplete application later.

6. Staffing, Training and Background Checks

The Pennsylvania DHS classifies Supports Coordination as a "high" categorical risk level for Medicaid enrollment. This requires all persons with a 5% or greater ownership interest, as well as managing employees, to undergo extensive background checks, including FBI fingerprinting.

Direct-care Supports Coordinators must meet specific educational and experience thresholds, typically requiring a Bachelor's degree. Agencies must also maintain a designated Supports Coordinator Supervisor to oversee the clinical and administrative functions of the SC staff.

7. Documentation, Policies and Records

Approved SCOs must maintain comprehensive policy manuals that align with Chapter 51 or Chapter 52 regulations. These policies must be submitted during the qualification phase and implemented immediately upon approval.

Critical documentation includes a formal Quality Management (QM) Plan, an Incident Management policy utilizing the Enterprise Incident Management (EIM) system, and detailed protocols for conflict-free case management and participant rights.

8. Billing, Rates and Claims

Supports Coordination is billed in 15-minute increments using specific HCPCS procedure codes (e.g., T1016 or T2024) depending on the waiver and target population. Claims for ODP services are processed through PROMISe, while OLTL claims are submitted directly to the contracted CHC-MCOs.

For ODP, service authorization and ISP data are managed within the Home and Community Services Information System (HCSIS). Providers cannot bill for services unless the ISP is approved in HCSIS and the units are authorized.

9. Approval Sequence and Timeline

The pathway to becoming a billable SCO in Pennsylvania is strictly sequential. An entity must first establish its corporate structure and complete the required state orientation before submitting the provider qualification packet to ODP or OLTL.

Only after the state issues the qualification approval letter can the agency submit its PROMISe enrollment application. For OLTL providers, PROMISe enrollment is followed by the MCO credentialing and contracting phase, which can add several months to the timeline.

10. Common Denials and Survey Findings

Applications are frequently rejected at the PROMISe enrollment stage if the provider fails to include the required ODP or OLTL qualification letter, or if the high-risk background checks for owners and managing employees are incomplete.

During post-enrollment audits, state surveyors commonly cite SCOs for failing to complete required face-to-face monitoring visits within the mandated timeframes, or for employing Supports Coordinators who do not meet the strict degree and experience requirements.

11. Key Contacts and Resources

Prospective providers must utilize the official DHS portals and help desks to navigate the qualification and enrollment processes. The PROMISe portal serves as the central hub for Medicaid enrollment applications and fee-for-service claims.

For program-specific guidance, providers should reference the ODP or OLTL provider pages on the DHS website, which house the current waiver appendices, rate schedules, and provider bulletins.

See all Pennsylvania services · Pennsylvania Medicaid consulting · book a consultation.