PA Health & Wellness (Community HealthChoices)

Provider Alerts

On March 1st, 2022, our Community HealthChoices (Pennsylvania Medicaid) plan will switch over to CVS for our pharmacy claims processor. To ensure a smooth transition, all Medicaid members should update their pharmacy with their new ID card that they received in the mail. Please note the following changes:

BIN: 004336
PCN: MCAIDADV
GRP: RX5455

For claims related issues, the CVS Help Desk can be reached at 1-888-321-3120.

Additionally, the fax number for medication prior authorizations will change to 1-844-205-3386.

Please note that this update applies to CHC or Pennsylvania Medicaid only. This switch in pharmacy platforms should not impact any member's current pharmacy benefits. If you have additional questions, you can reach out to PHW member services at 1-844-626-6813.

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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

Complex imaging, MRA, MRI, PET, and CT scans need to be verified by NIA

Behavioral Health/Substance Abuse need to be verified by the respective Behavioral Health MCO

Non-participating providers must submit Prior Authorization for all services.

For non-participating providers, Join Our Network.

Effective 11-1-2020, Musculoskeletal Surgical Services Need to Be Verified by TurningPoint. Please contact TurningPoint by phone at 855-909-8222 or by fax at 717-303-5072.

Are Services being performed in the Emergency Department or Urgent Care Center, for Dialysis Service or Family Planning services billed with a Contraceptive Management diagnosis?

Yes No

Types of Services	YES	NO
Is the member being admitted to an inpatient facility?	serviceQuestion-0	serviceQuestion-0
Are anesthesia services being rendered for pain management or Dental services?	serviceQuestion-1	serviceQuestion-1
Are oral surgery services being provided in the office?	serviceQuestion-2	serviceQuestion-2
Are services, other than DME, orthotics, prosthetics, and supplies, being rendered in the home?	serviceQuestion-3	serviceQuestion-3
Is the member receiving hospice services?	serviceQuestion-4	serviceQuestion-4
Are services being rendered by a Chiropractor?	serviceQuestion-5	serviceQuestion-5

PA Health & Wellness (Community HealthChoices)

Are Services being performed in the Emergency Department or Urgent Care Center, for Dialysis Service or Family Planning services billed with a Contraceptive Management diagnosis?

Services being performed in the Emergency Department or Urgent Care Center or Family Planning services billed with a Contraceptive Management diagnosis do NOT require prior authorization

Enter the code of the service you would like to check:

To submit a prior authorization Login Here.