Pennsylvania Payer Configuration and Requirements Tables

The payer configuration table is a valuable resource to help you understand the specific requirements for each payer contract as they relate to the integration process. By referencing this table, you can ensure the correct configuration of payer contracts, maintain compliance, and streamline workflows. Use this topic as a quick reference to verify the scope of each payer’s requirements and to facilitate a smooth integration process.

Payer and Provider billable units must match in order to avoid payroll issues and recoupment later on. If you submit an invoice with this type of discrepancy, an error will appear and prompt you to adjust your billable units.

Payer Configurations and Requirements Amerihealth Caritas of PA Amerihealth EPSDT
835s Availability By Request Only Not in Scope
Billing Required Optional Not Required
Communications Module Availability Available Available
DX Code is Payer or Provider Managed Payer Managed Payer Managed
EVV Required Required Required
Payer GPS Tolerance 1,320 ft 1,320 ft
Missed Visits Required Not in Scope Not in Scope
POC Compliance Required Required Required
Rate is Payer or Provider Managed Payer Managed Billing not in Scope
Referring Physician Required Not Required Not Required
Payer Configurations and Requirements Centene PA Health & Wellness HHCS Centene PA Health & Wellness
835s Availability Not in Scope By Request Only
Billing Required Required Required
Communications Module Availability Available Available
DX Code is Payer or Provider Managed Payer Managed Payer Managed
EVV Required Required Required
Payer GPS Tolerance 1,320 ft 1,320 ft
Missed Visits Required Not in Scope Not in Scope
POC Compliance Required Required Required
Rate is Payer or Provider Managed Provider Managed Payer Managed
Referring Physician Required Required Not Required
Payer Configurations and Requirements Health Partners Plan
835s Availability Not in Scope
Billing Required Required
Communications Module Availability Available
DX Code is Payer or Provider Managed Payer Managed
EVV Required Required
Payer GPS Tolerance 1,320 ft
Missed Visits Required Not in Scope
POC Compliance Required Required
Rate is Payer or Provider Managed Provider Managed
Referring Physician Required Required
Payer Configurations and Requirements Highmark Wholecare
835s Availability Not in Scope
Billing Required Required
Communications Module Availability Not Available
DX Code is Payer or Provider Managed Provider Managed
EVV Required Required
Payer GPS Tolerance 1,320 ft
Missed Visits Required Not in Scope
POC Compliance Required Required
Rate is Payer or Provider Managed Provider Managed
Referring Physician Required Not Required
Payer Configurations and Requirements Keystone EPSDT Keystone First CHC
835s Availability Not in Scope Not in Scope
Billing Required Optional Not Required
Communications Module Availability Available Available
DX Code is Payer or Provider Managed Payer Managed Payer Managed
EVV Required Required Required
Payer GPS Tolerance 1,320 ft 1,320 ft
Missed Visits Required Not in Scope Not in Scope
POC Compliance Required Required Required
Rate is Payer or Provider Managed Billing not in Scope Payer Managed
Referring Physician Required Not Required Not Required
Payer Configurations and Requirements United Healthcare of Pennsylvania, Inc
835s Availability Not in Scope
Billing Required Required
Communications Module Availability Not Available
DX Code is Payer or Provider Managed Payer Managed
EVV Required Required
Payer GPS Tolerance 1,320 ft
Missed Visits Required Not in Scope
POC Compliance Required Required
Rate is Payer or Provider Managed Provider Managed
Referring Physician Required Not Required
Payer Configurations and Requirements UPMC LTSS UPMC Home Health/Home Nursing EPSDT
835s Availability Not in Scope By Request Only
Billing Required Required Required
Communications Module Availability Available Available
DX Code is Payer or Provider Managed Payer Managed Payer Managed
EVV Required Required Required
Payer GPS Tolerance 1,320 ft 1,320 ft
Missed Visits Required Not in Scope Not in Scope
POC Compliance Required Required Required
Rate is Payer or Provider Managed Payer Managed Provider Managed
Referring Physician Required Not Required Required