PA Medicaid Revalidation Initiative and Implications for Personal Assistance HCBS Providers

The Pennsylvania Department of Human Services (DHS) recently provided additional clarification regarding the Commonwealth’s response to a recent federal Medicaid program integrity directive issued by the Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz.

CMS directed all state Medicaid agencies to develop and submit a comprehensive two-year provider revalidation strategy that is focused on strengthening provider oversight, including enhanced review of higher-risk providers and providers operating without a National Provider Identifier (NPI). DHS indicated that it intends to rely on its existing provider screening framework established in the Department’s 2016 provider screening bulletin to determine which provider types will be considered “high risk” for purposes of enhanced revalidation activities.

What Providers Need to Know:

DHS Will Use Existing High-Risk Provider Categories

DHS indicated that only the provider types and sub-specialties specifically identified in its existing 2016 provider screening framework will be categorized as high risk for this initiative.

In addition, providers may be categorized as high risk if they meet certain program integrity triggers, including:

• Newly enrolling providers of home health services or durable medical equipment supplies;
• Providers subject to payment suspensions based on credible allegations of fraud, waste, or abuse;
• Providers excluded by the U.S. Department of Health and Human Services Office of Inspector General (OIG) or another state Medicaid program within the past 10 years;
• Providers with outstanding DHS overpayments greater than $1,500 that are more than 30 days old and not under appeal or repayment agreement; or
• Providers seeking enrollment following the lifting of a federally imposed enrollment moratorium.

Implications for Type 59 Attendant Care Providers

For many HCBS providers, the traditional personal assistance and home care providers operating under sub-specialty 362 do not appear to be included within the high-risk categories identified by DHS. However, Provider Type 59 Attendant Care providers are included within the identified high-risk framework and should anticipate additional revalidation activity or off-cycle review.

Providers should immediately verify their assigned provider sub-specialties within PROMISe to determine whether any service locations are associated with sub-specialty 050.

Implications for Providers Without an NPI

CMS specifically instructed states to develop strategies focused on “high-risk providers, including providers without an NPI.”

At this time, DHS has not released detailed operational guidance regarding how providers without NPIs will be handled under Pennsylvania’s implementation strategy. However, providers should be aware that non-NPI status may receive increased attention during future enrollment or revalidation reviews.

Providers operating without an NPI should:

• Review current enrollment structures;
• Confirm whether any service lines may eventually require NPIs;
• Ensure organizational and ownership information is fully current within PROMISe; and
• Prepare for possible future guidance related to non-NPI provider oversight.

Recommended Provider Actions

Verify Your Provider Type and Sub-Specialties: Log into PROMISe and review the provider type and sub-specialty assigned to each enrolled service location. To verify:

1. Log into PROMISe.
2. Select “ePEAP” from the menu.
3. View the provider number displayed at the top of the screen.
4. Select “View Specialties” on the right side of the screen.

Determine Whether Any Locations Fall Within Higher-Risk Categories: Providers should identify whether any service locations are enrolled under Provider Type 59 with sub-specialty 050 or any other categories previously identified by DHS as high risk. Organizations with multiple locations should review each enrolled site individually.

Review NPI Status: Providers should determine whether the organization currently maintains an NPI; which service lines operate with or without NPIs; and whether enrollment records accurately reflect current organizational structure. Even if NPIs are not currently required, providers should ensure all enrollment information is accurate and current.

Consider Revalidating Early: Providers already scheduled for revalidation in 2026 should consider beginning the process earlier rather than waiting until later in the year, when statewide revalidation volume may increase significantly. Early preparation may help avoid processing delays, documentation backlogs; enrollment interruptions; and payment disruptions.

Organize Revalidation Documentation Now: Providers should begin gathering and reviewing commonly requested enrollment and revalidation documentation, including:

• Ownership disclosures;
• W-9 documentation;
• Corporate organizational records;
• Insurance certificates;
• Licensure documentation;
• Compliance policies and procedures;
• Employee screening documentation;
• OIG exclusion screening records; and
• Any prior DHS correspondence regarding enrollment status.

Operational Considerations for HCBS Providers

HCBS providers should anticipate that DHS and CMS may place increased emphasis on:

• Provider enrollment accuracy;
• Ownership transparency;
• Exclusion screening;
• Claims oversight;
• Program integrity controls; and
• Documentation consistency across service locations.

Providers should also expect potential increases in reviews, requests for updated document, site verification activities, and screening-related communications.

Important Resources and Links

• CMS Medicaid Program Integrity Information
• HHS-OIG Exclusions Database (LEIE)
• Pennsylvania DHS Provider Enrollment Information
• PROMISe Portal

RCPA will continue monitoring DHS guidance and provide information as it becomes available. If you have any questions, please contact Fady Sahhar.