Medical Billing Services in Pennsylvania
Billing, coding, credentialing and denial management for Pennsylvania practices, with Medicare claims through Novitas Solutions (Jurisdiction JL) and Pennsylvania Medicaid handled by people who know the rules.
Medical billing for Pennsylvania practices
Pennsylvania has a regional commercial market. Independence Blue Cross dominates Philadelphia, Highmark leads in western and central Pennsylvania, and Capital Blue Cross covers the Harrisburg area, with UPMC Health Plan and Geisinger also large. Medical Assistance members are mostly in HealthChoices managed care, and older adults and adults with physical disabilities who need long-term services are in Community HealthChoices.
Medicare Part B claims go to Novitas Solutions in Jurisdiction L. Fee-for-service Medical Assistance claims run through PROMISe with a 180-day filing limit. SFA Solutions works with practices across Pennsylvania remotely from Austin, from Philadelphia to Pittsburgh and the rural counties in between, inside your current EHR, with most clean claims submitted within 24 hours.
Pennsylvania at a glance
| Medicare contractor | Novitas Solutions, Jurisdiction JL |
|---|---|
| Medicaid timely filing | 180 days from the date of service for fee-for-service claims (55 Pa. Code 1101.68); HealthChoices plans set their own limits by contract |
| NP practice authority | Reduced |
| Cities we serve | Philadelphia, Pittsburgh, Allentown, Erie, Reading, Scranton, Harrisburg, Lancaster, Bethlehem, State College |
What Pennsylvania billing involves
These are the programs and rules our team works with for Pennsylvania claims.
Medicare
Novitas Solutions · JLPennsylvania Part B claims are processed by Novitas Solutions in Jurisdiction JL. Medicare's filing limit is 12 months from the date of service, and appeals start with a redetermination within 120 days of the initial decision.
Pennsylvania Medicaid
Pennsylvania Medical Assistance (Medicaid), administered by the Department of Human Services (DHS); HealthChoices for physical and behavioral health managed care, and Community HealthChoices for long-term services and supports
Portal: PROMISe, the DHS claims processing and provider enrollment system for fee-for-service Medical Assistance
Medicaid managed care
Most members are enrolled in a Physical HealthChoices plan, with options that vary by zone, including AmeriHealth Caritas, Geisinger Health Plan, Jefferson Health Plans EverWell, Highmark Wholecare, Keystone First, UPMC for You and UnitedHealthcare Community Plan. Behavioral health is managed separately through Behavioral HealthChoices.
Timely filing
180 days from the date of service for fee-for-service claims (55 Pa. Code 1101.68); HealthChoices plans set their own limits by contract.
Commercial and Medicare Advantage
Highmark, Independence Blue Cross, Capital Blue Cross, UPMC Health Plan and Geisinger Health Plan are the largest commercial carriers, with Aetna and UnitedHealthcare also active. UPMC, Highmark, Aetna and Humana all offer Medicare Advantage plans in the state.
Prompt pay law
Pennsylvania's Act 68 and its regulation (31 Pa. Code 154.18) require licensed insurers and managed care plans to pay clean claims within 45 days of receipt.
Nurse practitioners
Reduced practicePennsylvania CRNPs need a written collaborative agreement with a physician. To prescribe, they also need a prescriptive authority collaborative agreement that names a collaborating physician and at least one substitute physician (49 Pa. Code 21.285). NPs bill under their own NPI, and plans may ask for the agreements during credentialing.
Credentialing
Enroll with Medical Assistance through DHS before contracting with HealthChoices plans, which require an active Medicaid enrollment. Highmark, Independence, Capital Blue Cross and UPMC Health Plan use CAQH ProView. Ordering and referring providers must also be enrolled with Medical Assistance, and enrollment must be revalidated at least every five years.
Billing challenges Pennsylvania practices face
Regional Blue plans
Pennsylvania has several Blue plans, and the right one depends on the patient's plan and location. Claims sent to the wrong Blue plan or missing BlueCard routing are a common source of delays.
Behavioral health carve-out
HealthChoices behavioral health services are managed by county-based behavioral health plans, separate from the member's physical health plan. Practices offering both need to send each service to the right payer.
A 180-day Medical Assistance filing limit
PROMISe rejects fee-for-service claims received more than 180 days after the date of service unless an exception applies. Exception requests have their own deadlines, so it is better to never need them.
Our services in Pennsylvania
Medical Billing
Learn moreCredentialing & Payer Enrollment
Learn moreMedical Coding
Learn moreDenial Management
Learn moreA/R Recovery
Learn moreEligibility Verification & Prior Authorization
Learn moreMedical Billing Audit
Learn moreRevenue Cycle Management
Learn moreSpecialties we bill in Pennsylvania
Pennsylvania medical billing questions
What is the timely filing limit for Pennsylvania Medicaid?
Fee-for-service Medical Assistance claims must be received within 180 days of the date of service under 55 Pa. Code 1101.68. HealthChoices plans set their own filing limits by contract. Check each plan's provider manual.
How quickly must Pennsylvania insurers pay clean claims?
Act 68 requires licensed insurers and managed care plans to pay clean claims within 45 days of receipt. Self-funded ERISA plans generally follow federal rules.
Who is the Medicare contractor for Pennsylvania?
Novitas Solutions processes Medicare Part A and Part B claims for Pennsylvania under Jurisdiction L.
Do Pennsylvania nurse practitioners need a collaborating physician?
Yes. Pennsylvania CRNPs need a collaborative agreement with a physician, and a prescriptive authority agreement naming a collaborating physician and at least one substitute physician in order to prescribe. The NP still enrolls and bills under their own NPI.
Get a free billing audit for your Pennsylvania practice
We will review your recent claims and denials against Pennsylvania payer rules and show you what can be recovered.
Nearby states
Primary sources
- CMS: Who are the MACs, A/B MAC Jurisdiction L (JL)
- PA DHS: Managed Care Organizations, Physical HealthChoices
- PA DHS: PROMISe
- 55 Pa. Code 1101.68 (Cornell LII)
- 31 Pa. Code 154.18 Prompt payment (Cornell LII)
- 49 Pa. Code 21.285 Prescriptive authority collaborative agreements (Cornell LII)
Payer rules change. Last reviewed against the primary sources above on . Confirm current rules with the payer before relying on them.
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