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PA Health & Wellness (Community HealthChoices)

Provider Alerts

On January 1st, 2024, our Community HealthChoices (Pennsylvania Medicaid) plan will switch over to Express Scripts for our Pharmacy Benefits Manager. 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:

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.

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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

All out-of-network services require Prior Authorization except for family planning, emergency room, post-stabilization services and tabletop x-rays.

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?

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