Pennsylvania - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements
Last reviewed: 2026-09-10
Pennsylvania regulates in-home skilled nursing services through the Department of Health's Division of Home Health, requiring providers to obtain a Home Health Care Agency license under 28 PA Code Chapter 601 before billing Medicaid.
Approval to deliver these RN and LPN services under the Community HealthChoices (CHC) waiver mandates both state licensure and subsequent enrollment through the Department of Human Services' PROMISe portal as a high-risk provider.
1. Service Definition and Scope
In Pennsylvania, skilled nursing services delivered in the home are defined under 28 PA Code Section 601.32 as high-intensity comprehensive, planned services provided by a registered professional nurse, or by a licensed practical nurse under RN supervision.
These services are covered under the medical assistance program when ordered by a physician and integrated into a formal plan of treatment.
- Service Name: Skilled Nursing Services
- Governing Regulation: 28 PA Code Chapter 601
- Delivery Setting: Consumer's place of residence
- Eligible Providers: Registered Nurses (RN) and Licensed Practical Nurses (LPN)
- Supervision Requirement: LPNs must operate under the direct supervision of an RN
- Physician Order: Required for all skilled nursing interventions and treatment plans
2. Regulatory and Oversight Agencies
The Pennsylvania Department of Health (DOH) handles the primary licensure of Home Health Care Agencies, which is the required vehicle for providing skilled nursing.
The Department of Human Services (DHS) manages Medicaid enrollment, while Community HealthChoices (CHC) Managed Care Organizations administer the waiver benefits.
- Licensing Agency: Pennsylvania Department of Health, Division of Home Health (https://www.pa.gov/agencies/health/facilities/out-patient-healthcare-facilities/home-health/licensure)
- Medicaid Agency: Pennsylvania Department of Human Services (https://www.pa.gov/services/dhs/enroll-as-a-medicaid-provider)
- Enrollment Portal: PROMISe Provider Portal (https://promise.dhs.pa.gov/portal/provider/Home/tabid/135/Default.aspx)
- Waiver Program: Community HealthChoices (CHC) HCBS Waiver
- MCO Oversight: CHC Managed Care Organizations (e.g., PA Health and Wellness)
3. Gatekeeping Prerequisites: Who Can Even Apply
Pennsylvania does not enroll standalone independent nursing agencies for this waiver service without a facility license; an applicant must first be licensed as a Home Health Care Agency by the DOH.
This structural precondition means an agency must be staffed and equipped to provide skilled nursing care and at least one other therapeutic service (such as physical therapy or home health aides) to even submit a licensure application.
- Facility License Prerequisite: Must obtain a Home Health Care Agency license from PA DOH
- Service Scope Prerequisite: Must offer skilled nursing plus at least one other therapeutic service
- Medicare Certification: State licensure as a home health agency is a requirement for federal Medicare certification
- MCO Network Status: Enrollment in Medicaid does not guarantee MCO contracting; networks may be closed due to network adequacy
4. Licensure and Certification Requirements
Applicants must submit the Initial Home Health Application to the DOH Division of Home Health along with the required statutory fee.
Agencies seeking federal Medicare certification must also submit CMS Form 1572(a) and CMS Form 690 to the Division of Home Health.
- Application Form: Initial Home Health Application
- Submission Method: Email to [email protected] with physical mail for the fee
- Licensure Fee: $250 application or renewal fee as established by the Health Care Facilities Act
- Medicare Form 1: CMS Form 1572(a)
- Medicare Form 2: CMS Form 690
5. Medicaid Provider Enrollment
Once licensed, the agency must enroll through the DHS PROMISe Provider Portal. Skilled nursing providers are categorized at a high categorical risk level under the Affordable Care Act.
This risk level triggers enhanced screening requirements, including comprehensive ownership disclosures and background checks for all individuals with a 5 percent or greater ownership interest.
- System Name: PROMISe Provider Portal
- Risk Category: High categorical risk level per MA Bulletin 99-17-03
- Ownership Disclosure: Required for any person with a 5 percent or greater direct or indirect ownership interest
- Out-of-State Providers: Must provide documentation of participation in their home state's Medicaid program
- Change of Ownership: Requires submission of the Ownership and Control Interest Form to [email protected]
6. Staffing, Training and Background Checks
Direct care workers providing skilled nursing must hold a valid nurse's license in the Commonwealth of Pennsylvania.
Because the provider type is designated as high risk, stringent criminal background clearances are mandated for both staff and owners before services can commence.
- RN Requirement: Must hold a current and valid RN license in Pennsylvania
- LPN Requirement: Must hold a current and valid LPN license under the Practical Nurse Law (63 P.S. Sections 651-667)
- Federal Clearance: Federal Bureau of Investigation (FBI) criminal background check required
- State Clearance: Pennsylvania State Police Criminal Record Check required
- Experience Standard: The skilled nursing services must be under the direction of a physician or an RN with at least 1 year of nursing experience
7. Documentation, Policies and Records
Agencies must maintain comprehensive clinical records that demonstrate adherence to the physician-ordered plan of treatment.
The supervising registered nurse is responsible for documenting the initial evaluation and regularly reevaluating the patient's nursing needs.
- Treatment Plan: Must be initiated and revised by the registered nurse
- Clinical Notes: RNs and LPNs must prepare ongoing clinical and progress notes
- Evaluation Records: Initial evaluation visit must be documented by the RN
- Personnel Files: Must include a copy of the current nurse's license or certification
- Aseptic Technique Logs: LPNs must document preparation of equipment and materials observing aseptic techniques
8. Billing, Rates and Claims
Reimbursement for skilled nursing under the CHC waiver is processed through the participant's selected Managed Care Organization, not directly through fee-for-service Medicaid.
Providers must negotiate rates and secure contracts with the regional CHC MCOs after obtaining their PROMISe ID.
- Billing System: Claims are submitted to the respective CHC MCO
- Prior Authorization: All out-of-network services require prior authorization from the MCO
- Rate Setting: Negotiated via contracts with CHC MCOs (e.g., PA Health and Wellness, UPMC)
- Covered Service: Reimbursable under the MA Program only if a physician orders the services
- Claim Prerequisite: Must have an active PROMISe provider number linked to the MCO contract
9. Approval Sequence and Timeline
The critical path to billing begins with entity formation and DOH Home Health Care Agency licensure, which cannot be bypassed.
Only after the DOH issues the license can the agency apply for a PROMISe ID through DHS, followed by the final step of MCO credentialing.
- Step 1: Submit Initial Home Health Application and fee to DOH
- Step 2: Pass DOH initial licensure survey
- Step 3: Submit PROMISe enrollment application with high-risk background checks
- Step 4: Receive Medicaid Provider ID from DHS
- Step 5: Apply for network inclusion with regional CHC MCOs
10. Common Denials and Survey Findings
Applications are frequently delayed or denied due to incomplete high-risk background checks for owners or failure to offer a second therapeutic service.
During surveys, DOH inspectors commonly cite agencies for inadequate RN supervision documentation over LPNs.
- Denial Reason 1: Failure to submit FBI and State Police checks for 5 percent owners
- Denial Reason 2: Applying for skilled nursing without offering a second therapeutic service
- Survey Finding 1: Missing or expired RN/LPN licenses in personnel files
- Survey Finding 2: Lack of physician signatures on updated plans of treatment
- Survey Finding 3: Incomplete Ownership and Control Interest Forms during changes of ownership
11. Key Contacts and Resources
Providers should utilize the official Commonwealth portals for the most current applications, bulletins, and fee schedules.
The DOH Division of Home Health and the DHS Provider Enrollment unit are the primary regulatory contacts.
- DOH Home Health Licensure: https://www.pa.gov/agencies/health/facilities/out-patient-healthcare-facilities/home-health/licensure
- DHS Provider Enrollment: https://www.pa.gov/services/dhs/enroll-as-a-medicaid-provider
- PROMISe Portal: https://promise.dhs.pa.gov/portal/provider/Home/tabid/135/Default.aspx
- Initial Application Email: [email protected]
- Change of Ownership Email: [email protected]
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