Pennsylvania - Transitional Assistance Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Pennsylvania Department of Human Services (DHS) Office of Long-Term Living (OLTL) funds one-time institutional discharge expenses under the title Community Transition Services through the Community HealthChoices (CHC) and OBRA waivers. Providers must enroll through the PROMISe portal and subsequently secure network contracts with the regional CHC Managed Care Organizations (MCOs) that administer the benefit.

Approval requires an existing designation as a Service Coordination agency, Home Health Agency, or Durable Medical Equipment (DME) supplier, as standalone transition agencies are not recognized. The service covers up to $4,000 per participant per lifetime for essential setup expenses like security deposits and basic furnishings when moving from a nursing facility to a private residence.

1. Service Definition and Scope

Community Transition Services cover one-time expenses for individuals transitioning from an institution to a private residence where they are responsible for their own living expenses. The service is limited to the purchase of specific items to facilitate the transition, not the ongoing supports or activities provided to obtain the items.

These services are authorized under the Community HealthChoices (CHC) and OBRA waivers to help participants establish a basic household after a prolonged institutional stay.

• Funding Limit: capped at an aggregate of $4,000 per participant, per lifetime.
• Eligible Expenses: security deposits, essential furnishings, window coverings, and basic household items.
• Excluded Expenses: monthly rental or mortgage expenses, food, and regular utility charges.
• Waiver Authorities: Community HealthChoices (CHC) Waiver and OBRA Waiver.
• Pre-authorization: requires approval by the State Medicaid Agency program office or the participant's CHC MCO.

2. Regulatory and Oversight Agencies

The Department of Human Services (DHS) Office of Long-Term Living (OLTL) oversees the CHC and OBRA waivers and sets the service definitions. Because CHC operates as a managed care program, the contracted Managed Care Organizations (MCOs) handle direct provider network management, credentialing, and claims processing.

Providers must interact with both the state for baseline Medicaid enrollment and the MCOs for actual service authorization and payment.

• Department of Human Services (DHS): administers the state Medicaid program (https://www.dhs.pa.gov).
• Office of Long-Term Living (OLTL): manages HCBS waivers including CHC and OBRA (https://www.dhs.pa.gov/about/DHS-Information/Pages/Office-of-Long-Term-Living.aspx).
• PA Health & Wellness: CHC MCO handling regional credentialing and claims (https://www.pahealthwellness.com).
• UPMC Community HealthChoices: CHC MCO managing participant service plans and provider networks (https://www.upmchealthplan.com/chc/).
• AmeriHealth Caritas Pennsylvania: CHC MCO overseeing provider contracting for transition services (https://www.amerihealthcaritaschc.com).

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania does not enroll standalone Community Transition Services providers. Applicants must already hold or simultaneously obtain approval as a specific provider type, such as a Service Coordination agency, Home Health Agency, or Durable Medical Equipment (DME) supplier.

Furthermore, because the CHC waiver operates under a managed care model, PROMISe enrollment alone does not guarantee patient referrals; providers must secure active contracts with the regional CHC MCOs to receive authorizations and payment.

• Provider Type Restriction: must be an enrolled Service Coordination agency, Home Health Agency, or DME Supply Company.
• MCO Network Contracting: requires active credentialing and contracting with at least one CHC MCO (e.g., PA Health & Wellness) to receive authorizations.
• Institutional Stay Requirement: participants must have resided in an institution for at least 30 consecutive days prior to transition.
• Geographic Location: must have a waiver service location in Pennsylvania or a contiguous state.

4. Licensure and Certification Requirements

There is no specific Community Transition Services license in Pennsylvania. Instead, providers must maintain the underlying licensure or certification required for their primary provider type under 55 PA Code Chapter 52.

Agencies must ensure they meet all state and federal standards applicable to their base operational category before adding transition services to their profile.

• Home Health Agencies: must hold a Home Health Agency license from the Pennsylvania Department of Health.
• Service Coordination Agencies: must meet OLTL conflict-free case management standards and qualifications.
• DME Suppliers: must maintain appropriate business licenses and Medicare DMEPOS certification if applicable.
• Driver's License: staff must hold a valid driver's license from PA or a contiguous state if vehicle operation is necessary to provide the service.

5. Medicaid Provider Enrollment

Providers must enroll in the Pennsylvania Medicaid program through the Provider Reimbursement and Operations Management Information System (PROMISe). The enrollment process requires submitting the Home and Community-Based Waiver Services Provider Enrollment Information Form.

Enrollment must be maintained actively, with revalidation required periodically to ensure ongoing compliance with state regulations.

• Enrollment Portal: PROMISe electronic enrollment system (https://promise.dpw.state.pa.us).
• Required Form: Home and Community-Based Waiver Services Provider Enrollment Information Form.
• Provider Agreement: must sign and comply with the standard Medicaid waiver provider agreement per 55 PA Code 1101.
• Revalidation: required at the time of enrollment and at least every five years, or more frequently when deemed necessary by OLTL.

6. Staffing, Training and Background Checks

Staff facilitating community transitions must meet the baseline qualifications for their respective provider agencies. This includes mandatory background clearances and training on HCBS waiver requirements.

Agencies are responsible for maintaining personnel files that document compliance with all state-mandated training and clearance protocols.

• Criminal Background Checks: required for all staff with direct participant contact, processed through the Pennsylvania State Police.
• Child Abuse Clearances: required if the provider serves individuals under age 18.
• Training Requirements: staff must complete OLTL-mandated training on incident management and participant rights.
• Service Coordinator Qualifications: must possess a bachelor's degree in a human services field or equivalent experience as defined by OLTL.

7. Documentation, Policies and Records

Providers must maintain detailed records of all transition expenses and coordinate closely with the participant's Service Coordinator. Documentation must prove that funds were spent exclusively on allowable setup costs.

All purchases must be explicitly tied to the participant's approved service plan and retained for audit purposes.

• Expense Receipts: must retain itemized receipts for all purchased goods (e.g., furniture, deposits) for state or MCO auditing.
• Person-Centered Service Plan (PCSP): transition items must be explicitly documented and authorized in the participant's PCSP.
• Record Retention: must keep all financial and service records for a minimum of five years per 55 PA Code Chapter 1101.
• Incident Management Policy: must maintain and follow an OLTL-approved policy for reporting critical incidents.

8. Billing, Rates and Claims

Billing for Community Transition Services is routed through the participant's CHC MCO rather than directly to the state, except for OBRA waiver participants not in managed care. Providers cannot bill for the service until the date the person actually enters the waiver program and leaves the institution.

Claims must accurately reflect the exact cost of the items purchased, up to the lifetime maximum.

• Billing Trigger: claims may only be submitted on or after the date of the participant's discharge from the institution.
• Maximum Cap: total claims cannot exceed the $4,000 lifetime aggregate limit per participant.
• Claim Submission: routed through the respective MCO provider portals (e.g., PA Health & Wellness Provider Portal).
• Service Codes: billed using specific HCPCS codes designated by OLTL and the MCOs for transition expenses.

9. Approval Sequence and Timeline

The approval process begins with establishing the base provider type and enrolling in PROMISe. Once state Medicaid enrollment is active, the provider must apply to join the provider networks of the regional CHC MCOs.

Providers should anticipate a multi-month process to complete both state enrollment and MCO credentialing.

• Step 1: Obtain underlying licensure (e.g., DOH Home Health license) or certification.
• Step 2: Submit the HCBS Provider Enrollment Information Form and PROMISe application to OLTL.
• Step 3: Receive the PROMISe Provider ID (typically takes 30-60 days).
• Step 4: Apply for credentialing and contracting with CHC MCOs (adds 60-90 days).

10. Common Denials and Survey Findings

Applications and claims are frequently denied if the provider fails to secure MCO contracts or attempts to bill for unallowable expenses. Audits often target missing receipts or transition funds spent on ongoing living costs.

Strict adherence to the allowable expense list and proper timing of claim submissions are critical to avoiding recoupment.

• Unallowable Expenses: claims denied for billing monthly rent, food, or entertainment items instead of one-time setup costs.
• Premature Billing: claims rejected if submitted before the participant's actual discharge date from the nursing facility.
• Missing MCO Contract: PROMISe enrollment alone does not guarantee payment; claims deny if the provider is out-of-network with the participant's MCO.
• Documentation Failures: recoupment of funds during audits due to missing itemized receipts for purchased goods.

11. Key Contacts and Resources

Providers should utilize the official state portals and MCO provider relations departments for enrollment and billing support. The OLTL provider helpline is the primary contact for PROMISe enrollment issues.

Maintaining active communication with the MCOs is essential for navigating authorizations and claims.

• DHS Office of Long-Term Living (OLTL): https://www.dhs.pa.gov/about/DHS-Information/Pages/Office-of-Long-Term-Living.aspx
• PROMISe Provider Portal: https://promise.dpw.state.pa.us
• PA Health & Wellness Provider Portal: https://www.pahealthwellness.com/providers.html
• UPMC Community HealthChoices Providers: https://www.upmchealthplan.com/providers/chc/
• AmeriHealth Caritas PA Providers: https://www.amerihealthcaritaschc.com/provider/index.aspx

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