Pennsylvania's Medicaid home care program is called Community HealthChoices — and if you serve both CHC managed care members and fee-for-service waiver members, you're living in two different billing worlds simultaneously. HHAeXchange for CHC members. Sandata through PROMISe for FFS. The EVV compliance threshold is now 85%. And every CHC member's services flow through one of three MCOs, each with its own credentialing timeline. Here is what a Pennsylvania operator actually needs to know.
Community HealthChoices (CHC) is Pennsylvania's mandatory long-term services and supports managed care program, administered by DHS through OLTL (Office of Long-Term Living). If you serve dual-eligible adults or adults 21+ with physical disabilities who qualify for LTSS, they are almost certainly in CHC. Being enrolled as a Pennsylvania Medicaid provider gives you the right to serve them. Being credentialed with their specific MCO gives you the ability to get paid for doing so.
CHC launched in three zones: Southwest Pennsylvania in 2018, Southeast in 2019, and the rest of the state in 2020. It is now fully statewide. Every eligible member chooses one of three MCOs — and if they don't choose, the state assigns one. Services are authorized and paid by the MCO, not by the state directly. Authorization requests, prior authorization processes, timely filing windows, and billing dispute contacts are all MCO-specific.
Serves the Southeast region (Philadelphia, Bucks, Chester, Delaware, Montgomery, and other SE counties). Known as AmeriHealth Caritas Pennsylvania in the Southwest zone. Contact: 1-855-332-0729.
Credentialing contact: [email protected]
Centene subsidiary. Available statewide. Contact: 1-844-626-6813.
Credentialing contact: [email protected]
UPMC Health Plan's CHC product. Strong presence in Western PA and the Pittsburgh region. Available statewide. Contact: 1-844-833-0523.
Credentialing contact: Contact UPMC Health Plan provider network directly.
Credentialing with each plan is a separate process on each plan's independent timeline. If you serve members enrolled in multiple CHC plans — which most agencies do — you need active credentialing with each plan. Being credentialed with one CHC MCO gives you no standing with the others. If a member switches plans mid-service, your ability to continue billing for that member depends on whether you're credentialed with their new plan.
Highmark WholeCAre also participates in Pennsylvania's Medicaid managed care ecosystem for physical health HealthChoices (not CHC LTSS) and transitioned to HHAeXchange effective November 1, 2024 for its home health EVV requirements.
Pennsylvania runs an open EVV model, which means providers can use their own EVV system as long as it integrates with the state's platforms. But the more immediate operational issue is that the CHC managed care pathway and the fee-for-service OLTL pathway use different EVV systems — and agencies serving both populations must be live on both.
All three CHC MCOs (Keystone First, PA Health & Wellness, UPMC) use HHAeXchange as their shared EVV and claims submission platform. HHAeXchange is offered free to providers for the state-sponsored portal version. Telephony clock-in/clock-out with a toll-free 800 number is included.
EVV records captured in HHAeXchange trigger claim creation to the MCO once the visit is confirmed. Authorization data flows into the portal from the MCO in real time. Agencies with their own EVV system can integrate via EDI — visit data imports from your system into HHAeXchange, which then creates and submits the claim to the MCO.
The EVV compliance threshold for CHC services is 85% effective January 1, 2025, up from 50%. Agencies tracking just above the old threshold need to close that gap or face corrective action.
For fee-for-service members receiving OLTL waiver services (Act 150, some OBRA waivers) or OMAP personal care, Pennsylvania uses a Sandata-based EVV system accessed through the PROMISe provider portal — the state's Medicaid billing system.
HHAeXchange sends EVV data to Sandata as EDI files for state-level aggregation. Agencies billing both CHC and FFS pathways must maintain both connections — HHAeXchange for MCO visits, Sandata/PROMISe for FFS visits.
For participant-directed programs under OLTL waivers (self-directed care), the vendor fiscal agent PPL (Public Partnerships LLC) uses the Time4Care EVV system. Agencies providing agency-directed services in those programs use the standard HHAeXchange or Sandata pathways depending on how the member is enrolled.
October 2024: HHAeXchange acquired Sandata Technologies. Pennsylvania providers who had been managing two separate platform relationships are increasingly seeing those platforms align. Watch for DHS and OLTL bulletins for any consolidation changes to Pennsylvania's EVV infrastructure as the acquisition integration proceeds.
Pennsylvania home care agencies providing non-medical home care must be licensed under Chapter 611 of the Pennsylvania Code, administered by the PA Department of Health. This license covers homemaker, companion, and personal care services. The licensing requirements include:
| Requirement | Detail | Common Gap |
|---|---|---|
| PA Dept. of Health Chapter 611 License | Required for non-medical home care services. Applies to all homemaker, companion, and personal care agencies. | License must be current and in the agency's legal name matching Medicaid enrollment records before credentialing with MCOs. |
| Criminal Background Checks | All direct care workers require Pennsylvania State Police criminal history report, FBI fingerprint check (if lived outside PA in last 2 years), and child abuse clearance. | Missing one of the three clearances — especially the child abuse clearance — is the most common licensing audit deficiency. |
| OLTL Medicaid Provider Enrollment | Enroll through DHS/OLTL to receive a Medicaid provider ID and approved service/procedure codes. Required before MCO credentialing. | Agencies sometimes begin MCO credentialing before completing OLTL enrollment — MCOs require the state provider ID as part of their application. |
| MCO Credentialing | Separate process with each of the three CHC MCOs. Each has its own application, timeline (typically 60–120 days), and documentation requirements. | Assuming that credentialing with one MCO transfers to the others. It doesn't. Each plan is independent. |
| HHAeXchange Portal Setup | Must be completed for CHC member billing. Free version available; enterprise features require subscription. Complete the provider questionnaire via hhaexchange.com/pachc/. | Starting provider setup after the first CHC referral arrives, rather than before. Claims cannot be created until the HHAeXchange portal is active. |
Community HealthChoices is the mandatory MLTSS program for long-term services and supports — personal care, homemaker, and related HCBS for dual-eligible adults and adults with physical disabilities. Regular HealthChoices is the physical health managed care program for other Medicaid members. CHC members get their LTSS through a CHC MCO. CHC is administered by OLTL. Agencies providing home-based personal care and homemaker services to dual-eligible or physically disabled adults are almost entirely in the CHC world, not the broader HealthChoices physical health world.
CHC managed care members use HHAeXchange — the three CHC MCOs selected it as their shared EVV and billing platform. Fee-for-service OLTL waiver members use Sandata through the PROMISe state portal. If you serve both populations, you need both. Most agencies serving CHC members primarily use HHAeXchange and set up Sandata for the smaller FFS population. Agencies with their own EVV software can integrate with both platforms via EDI rather than running two separate apps. HHAeXchange acquired Sandata in October 2024, so watch for platform consolidation updates.
The EVV compliance threshold increased to 85% effective January 1, 2025. This means at least 85% of visits for services requiring EVV must have complete, unmodified EVV records. Agencies below this threshold receive compliance notices and may face corrective action plans. The Pennsylvania Homecare Association and HHAeXchange both publish resources on improving compliance rates — the most common issues are missed clock-outs, telephony failures on visits where caregivers have no mobile data, and visits that cross midnight not being split correctly in the system.
W1793 is a Pennsylvania-specific HCPCS code used for companion and personal care services billed under Community HealthChoices through the CHC MCOs. The CHC MCO-approved billing code list — available through HHAeXchange's Pennsylvania CHC information hub — specifies which codes to use for which service types. Using the wrong procedure code for a service type is one of the most common claim rejection causes in CHC billing. Verify your service-to-code mapping with each MCO's billing manual before submitting claims, because the approved code list is maintained by HHAeXchange and updated periodically.
Pennsylvania agencies running CHC MCO billing through HHAeXchange alongside FFS waiver billing through PROMISe, while maintaining 85% EVV compliance across both systems, are managing significant technical overhead on top of daily operations. CareBravo delivers scheduling, integrated EVV compliance across both pathways, billing to all three CHC MCOs, and authorization tracking as completed operational work. The procedure code matching requirements for CHC billing — including W1793 for applicable services — are managed within the system rather than requiring manual cross-reference between MCO billing manuals and claims.
Agencies that treat HHAeXchange and PROMISe as two separate billing problems — and MCO credentialing as a one-time event — end up with billing gaps every time a member changes plans or a Sandata record doesn't match a CHC claim. The CareDrain Diagnostic shows what your specific operational gaps are costing monthly before you decide how to fix them.