Community HealthChoices and WellKids by PA Health and Wellness (CHIP)
Provider Alerts
In 2024, our Community HealthChoices Plan (Pennsylvania Medicaid) switched over to Express Scripts for our Pharmacy Benefits Manager. Please note the following:
Community HealthChoices (CHC)
BIN: 003858
PCN: MA
GRP: 2FBA
For claims related issues, the Express Scripts Pharmacy Help Desk can be reached at 1-833-750-4504.
The fax number for medication prior authorizations will remain: 1-844-205-3386.
If you have additional questions, you can reach out to PHW member services at 1-844-626-6813.
DISCLAIMER: All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.
Vision Services need to be verified by Envolve Vision
Dental Services need to be verified by Envolve Dental
The following services need to be verified by Evolent: Complex Imaging, MRA, MRI, PET & CT scans; Musculoskeletal services for shoulder, hip, spine and knee surgery.
For Community HealthChoices, Behavioral Health/Substance Abuse need to be verified by the respective Behavioral Health MCO
All out-of-network services require Prior Authorization except for family planning, emergency room, post-stabilization services and tabletop x-rays.
Prior Authorization at a Glance
Prior Authorization is NOT Required
The following services do NOT require prior authorization:
- Services rendered in an emergency room or urgent care center
- Services rendered by a public health or welfare agency
- Family planning services billed with a contraceptive management diagnosis
Prior Authorization IS Required
The following services REQUIRE prior authorization:
- Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
- Admission of a member to an inpatient facility
- Hospice services
- Anesthesia services for pain management or dental procedures.
- Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
- Services rendered by a chiropractor
Prior Authorization Check
To submit a prior authorization Login Here
CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries
In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.
Reports:
- PA Health & Wellness CMS Final Rule 0057-F Prior Authorization Requirements (PDF)
- PA Health & Wellness Prior Authorization Metrics Summary (PDF)
The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.