Pennsylvania Medical Billing and Payer Rules

Timely Filing in Pennsylvania

Pennsylvania Law and the Federal No Surprises Act

Pennsylvania did not identify a state law setting the out-of-network rate, so the federal process decides these disputes for insured and self-funded plans alike. The Insurance Department enforces the outcome for insured plans.

Major Payers

How Does Pennsylvania Medical Assistance Work for Billing?

Pennsylvania's Medicaid program is called Medical Assistance (MA), and the Department of Human Services (DHS) runs it. The DHS Office of Medical Assistance Programs (OMAP) oversees the physical health side of the HealthChoices managed care program. Claims for fee-for-service members and the claim status tools run through the PROMISe provider portal.

Fee-for-service is the smaller piece. Most Pennsylvania MA members are in HealthChoices, which DHS describes as the state's mandatory managed care program for Medical Assistance recipients. A claim for one of those members goes to the member's managed care plan, not to PROMISe, so the first billing question is always which plan the member is enrolled in on the date of service.

Physical HealthChoices: Plans Change by Zone

The DHS Physical Health Managed Care page splits the state into five zones: Lehigh/Capital, Northeast, Northwest, Southeast and Southwest. Each zone has its own set of plans. The plans DHS lists across the zones are AmeriHealth Caritas (shown as AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast), Geisinger Health Plan, Highmark Wholecare, Jefferson Health Plans EverWell, Keystone First, UnitedHealthcare Community Plan and UPMC for You.

Only Geisinger Health Plan, Jefferson Health Plans EverWell and UPMC for You appear in all five zones. The rest vary: Keystone First and UnitedHealthcare Community Plan are listed only in the Southeast, and Highmark Wholecare only in Lehigh/Capital and the Southwest. A health system with campuses in two zones bills a different plan mix at each.

Behavioral HealthChoices: County Contracts

Mental health and substance use services are carved out of the physical plans. DHS says each county contracts with a managed care organization for these services, and each member is assigned a behavioral health MCO (BH-MCO) by county of residence. The DHS county map names CCBH, PerformCare, Carelon and MBH. Our behavioral health billing page covers the codes and authorization issues that follow from that split.

Community HealthChoices

Community HealthChoices (CHC) is the DHS program for people aged 21 or older who have both Medicare and Medicaid, or who receive long-term services and supports through Medicaid. DHS states that each of the five CHC zones is covered by all three CHC managed care organizations. For a provider, a dual-eligible patient in CHC means two payers on one claim, Medicare first and the CHC plan second, with separate rules at each.

What Is the Medical Assistance Timely Filing Limit in Pennsylvania?

An original Medical Assistance invoice must reach DHS within 180 days of the date of service. That limit is in 55 Pa. Code § 1101.68(b)(1), and the DHS billing FAQ repeats it. The word that matters is received: the clock runs until DHS receives the claim, and receipt is shown by the claim appearing on a remittance advice with a claim reference number (CRN).

The regulation counts calendar days, not business days.

Which Exceptions to the 180 Days Does DHS Allow?

Under 55 Pa. Code § 1101.68(c), DHS rejects invoices after 180 days unless one of two exceptions applies. The first: an eligibility determination was requested within 60 days of the date of service, and DHS receives the provider's exception request within 60 days of receiving that determination. The second: payment from a third party was requested within 60 days of the date of service, and DHS receives the exception request within 60 days of receiving the third party's statement.

• Exception requests go in writing to the Office of Medical Assistance Programs, with supporting documentation from the County Assistance Office or the third party and a correctly completed invoice (§ 1101.68(d)(1) and (2)).
• If DHS asks for more documentation and does not receive it within 30 days, it decides on what it has (§ 1101.68(d)(3)).
• An exception is granted one time. If the exception claim is then rejected for provider error, DHS grants no second exception (§ 1101.68(d)(4)).
• No exception is needed when the claim can still be submitted inside the 180 days, even if a third party or an eligibility decision is slow (§ 1101.68(d)(5)).

What About HealthChoices Plans?

The 180 days belongs to DHS and to fee-for-service claims. A HealthChoices plan sets its own filing window in its provider manual or contract, and this page cites no single statewide number for plans from an official DHS page. We load the window for each plan into the account at onboarding and track it separately from the DHS limit.

Who Is the Medicare Contractor in Pennsylvania?

Novitas Solutions is the Medicare Administrative Contractor (MAC) for Medicare Part A and Part B claims in Pennsylvania. The CMS list of MACs by state places Pennsylvania in Jurisdiction L (JL), together with Delaware, the District of Columbia, Maryland and New Jersey. Novitas also handles Part B for the Virginia counties of Arlington and Fairfax and the city of Alexandria.

Home health and hospice claims are different. The same CMS list shows Pennsylvania in the home health and hospice (HH+H) group of Jurisdiction 15, which belongs to CGS Administrators. A health system that owns a hospital and a home health agency in Pennsylvania therefore bills two different Medicare contractors. Our Medicare billing guide covers the mechanics.

Medicare's own timely filing rule is the same in every state. Under 42 CFR 424.44(a)(1), a Medicare claim for services furnished on or after January 1, 2010 must be filed no later than the close of the period ending one calendar year after the date of service. Paragraph (b) lets CMS extend that time when an error or misrepresentation by a Medicare contractor employee or agent caused the miss.

Hospitals bill Medicare on the UB-04; see hospital and facility billing.

What Is Pennsylvania's Prompt Payment Law?

Pennsylvania requires an insurer to pay a clean claim within 45 days of receiving it. The rule is Section 2166 of the Insurance Company Law of 1921, and Act 146 of 2022 rewrote it. A managed care plan that serves Medical Assistance or CHIP members has its own 45-day paragraph in the same section.

A clean claim, in the statute, is a claim for a health care service with no defect or impropriety. A defect includes missing substantiating documentation or a circumstance that needs special treatment and prevents timely payment. Claims from a provider under investigation for fraud or abuse regarding that claim are excluded. Our glossary entry on a clean claim sets this next to the federal definition.

The interest paragraph (b) is worded for insurers. The text cited here does not repeat the 10% interest for MA or CHIP managed care plans, so do not assume the same interest applies to a HealthChoices plan without checking the plan contract.

The statute defines an insurer as an entity licensed by the Insurance Department, so a self-funded plan that no licensed insurer underwrites is not described by it. Check the plan type before you cite Section 2166 in an appeal.

Does Pennsylvania Have Its Own Surprise Billing Law?

No. In its 2021 survey response to CMS, the Pennsylvania Insurance Department identified no state law that sets the out-of-network rate, and CMS concluded that the federal independent dispute resolution process applies in Pennsylvania. Out-of-network emergency and facility-based disputes therefore follow the federal No Surprises Act, not a Pennsylvania formula or Pennsylvania arbitration.

The CMS letter is dated December 23, 2021. It states that Pennsylvania has no All-Payer Model Agreement and named no state law as governing the out-of-network rate. It also records a collaborative enforcement agreement: the Insurance Department handles policy form review, investigations, market conduct exams and consumer assistance, and CMS steps in if the department cannot obtain voluntary compliance.

If you also bill in a neighboring state, compare New York, New Jersey and Ohio, and see our state surprise billing laws page for the full list.

Act 146 of 2022 Is Not a Surprise Billing Law

Act 146 of 2022 is often mentioned in connection with Pennsylvania billing, but the act is an omnibus amendment of the Insurance Company Law covering prior authorization, utilization review, external review and prompt payment. It touches surprise billing in one place: the disclosure each insurer must give about external review must tell covered persons they can request external review on whether the insurer complied with the surprise billing and cost-sharing protections of the No Surprises Act.

It also changed Section 2116 on emergency services. An insurer may not require prior authorization for an emergency service. The emergency health care provider must notify the insurer of the emergency and the patient's condition within two business days after the period of emergency, or notify an MA or CHIP managed care plan within ten days of presentation (§ 2116(a.1)).

What the Federal Law Covers in Pennsylvania

For emergency services at a hospital, hospital outpatient department, ambulatory surgical center or by air ambulance, the plan must cover them without prior approval whether or not the provider is in network. The department's page notes that ground ambulance services are not currently covered by the Act.

Uninsured and self-pay patients have their own federal route. Pennsylvania did not identify a state patient-provider dispute process, so CMS applies the federal process, under which the patient has 120 calendar days from the initial bill to start a dispute.

Ground Ambulance in Pennsylvania

The one place Pennsylvania law speaks directly is claim denial. Section 2116(b), as amended, says an insurer or MA or CHIP managed care plan may not deny a claim from a licensed emergency medical services agency solely because the enrollee did not require transport or refused transport. This page cites no Pennsylvania statute that bans balance billing for ground ambulance, so we do not tell clients that one exists.

How Do You Dispute an Out-of-Network Underpayment in Pennsylvania?

Use the federal process. Start open negotiation within 30 business days of the initial payment or denial notice, and if it fails, start federal IDR within 4 business days after the 30 business days of open negotiation end. Both periods are in 45 CFR 149.510, and neither changes because the claim is in Pennsylvania.

Our emergency medicine billing page covers the physician side, and out-of-network billing and IDR is the service we run for clients.

Which Payers Matter Most in Pennsylvania?

The Insurance Department's archived 2025 ACA rate filing page lists individual-market issuers including Highmark, Geisinger Health Plan, UPMC Health Coverage and UPMC Health Options, Keystone Health Plan East, QCC Insurance Company, Keystone Health Plan Central, Capital Advantage Assurance, PA Health & Wellness, Oscar Health Plan of PA and Health Partners Plans.

Medical Assistance adds the HealthChoices plans named above, and Medicare adds Novitas. For program-level rules see the Medicaid billing guide.

We do not rank these payers by size. The department's table shows market share by issuer and product, and it does not give a statewide ranking.

How We Handle Billing in Pennsylvania

We start each Pennsylvania account by mapping every campus to its zone, its HealthChoices plans and its county BH-MCO, then we set a separate filing clock for DHS fee-for-service claims. Claims go out within 24 hours of charge entry, and denials are worked within 48 hours, with the 180-day DHS limit and each plan's limit tracked on the account.

For underpaid out-of-network claims, we run open negotiation and federal IDR from first notice to final payment. Book a call and we will check your Pennsylvania payer mix first.