The PA PROMISe™ Provider Handbooks were written for the Pennsylvania Provider Reimbursement and Operations Management Information System (PA PROMISe™) providers who submit claims via the 837 Professional format or the CMS-1500 Claim Form, the 837 Institutional format or the UB-92 Claim Form, the NCPDP Version 5.1 Pharmacy transactions, and the 837 Dental format or the ADA Claim Form - Version 2000.

Four handbooks have been designed to assist PA PROMISe™ providers:

PA PROMISe™ Provider Handbook for the 837 Professional/CMS-1500 Claim Form
PA PROMISe™ Provider Handbook for the 837 Institutional/UB-92 Claim Form
PA PROMISe™ Provider Handbook for the 837 Dental/ADA Claim Form - Version 2000
PA PROMISe™ Provider Handbook for NCPDP 5.1/ Pharmacy Billing

The following sections detail the PA PROMISe™ providers who should access the PA PROMISe™ Provider Handbook for the 837 Professional/CMS-1500 Claim Form, a general overview of each section of the handbook, and how to obtain a hardcopy PA PROMISe™ Provider Handbook for the CMS-1500 Claim Form.

Note: The PA PROMISe™ Provider Handbooks have been designed to be fully functional as paper-based documents; however, providers will realize the full benefit of the handbooks when they access them in their online version.

1.1         PROMISe™ Provider Handbook for the 837 Professional/CMS-1500 Claim Form

The following PA PROMISe™ providers should access the PA PROMISe™ Provider Handbook for the 837 Professional/CMS-1500 Claim Form to obtain general information, eligibility verification instructions, Remittance Advice (RA) Interpretation, and billing instructions:

• Attendant Care
• Audiologists
• Birthing Centers
• Case Managers
• Certified Registered Nurse Anesthetists (CRNAs)
• Certified Registered Nurse Practitioners (CRNPs)
• Chiropractors
• Clinics (Except Outpatient Hospital Clinics)
• COMMCARE Waiver Services Providers
• Department of Health (DOH) Providers
• Employment Competitive Providers
• Extended Care Facilities for Respite Care Services
• Family Planning Clinics – Title XIX Only
• Funeral Directors
• Healthy Beginnings Plus Program Providers
• Home and Community Habilitation Services Providers
• Home Health Agency Providers
• Home Residential Rehabilitation Providers
• Homemaker Agency Providers
• Hospice Providers
• Independence & OBRA Waiver Providers
• Intermediate Service Organizations
• Laboratories
• LTC Exceptional Grant Payment Providers
• LTC Medicare Deductible & Coinsurance Payments
• MA Early Intervention (EI) Providers
• Medical Suppliers
• Medically Fragile Foster Care Providers
• Mental Health & Substance Abuse Providers (Including Outpatient Psychiatric Partial Hospitalization)
• Michael Dallas Waiver Providers
• Midwives
• Non-JCAHO Residential Treatment Facilities (RTFs)
• Nurse
• Nutritionist
• Office of Mental Retardation (OMR) Base Services and Waiver Services Providers
• Optometrist
• PDA Waiver Services Providers
• Personal Care Services Providers
• Physicians
• Podiatrists
• Psychologists
• Public Schools
• Rehabilitation Facilities
• Renal Dialysis Centers
• Rural Health Clinics/Federally Qualified Health Centers
• School Corporations
• Special Pharmaceutical Benefits Program
• Targeted Case Management Providers
• Therapists
• Tobacco Cessation Providers
• Transportation Providers (Ambulance Companies)
• TSM Case Management Services Providers
• Vendor
• X-Ray Clinics

1.2        PA PROMISe™ Provider Handbook for the 837 Professional/CMS-1500 Claim         Form Sections

This handbook contains the following sections:

Section 2 General Information	This section contains a high-level introduction for PA PROMISe™ providers, which includes information on the Commonwealth’s delivery systems, Freedom of Choice, invoicing options, time limits for claim submission, 180-Day Exception Request instructions, claim adjustment instructions, inquiries, Internet functions, and claim form reordering procedures.
Section 3 Policies	This section contains links to the Regulations, which pertain to PA PROMISe™ providers. For example, the PA PROMISe™ Provider Handbook for the CMS-1500 Claim Form will contain a link to the Pennsylvania Code, which houses Department of Public Welfare (DPW) Regulations. If a physician needs to access Medical Assistance (MA) policies specific to physicians, a link to 55 Pa. Code, Chapters 1101 (General Provisions), 1141 (Physicians’ Services), and 1150 (MA Program Payment Policies) will be provided to ensure that the physician is submitting claim forms in accordance with MA policy.
Section 4 Recipient Eligibility	This section reviews how to determine if a recipient is eligible for service(s), it describes the Pennsylvania ACCESS Cards, reviews program specific requirements for waivers and base programs, the Recipient Restriction/Lock-In Program, as well as Third Party Liability (TPL) and Medicare.
Section 5 Special Requirements for PA PROMISe™ Providers	This section contains information on Federally Required Forms and State Required Forms. It contains links to PA PROMISe™ policies surrounding the proper completion of these forms, when applicable, as well as links to the forms and their instructions.
Section 6 Provider Enrollment Information	This section contains information for a provider to understand how to enroll in the PA PROMISe™ Program. Provider information such as enrollment/provider agreements, provider notice information, changes to enrollment, provider certification, and provider responsibilities.
Section 7 Prior Authorization	This section reviews Prior Authorization (PA) requirements and includes instructions and information regarding Program Exception (PE), the Automated Utilization Review (AUR) Admission Certification Process, Place of Service Review (PSR), and administrative items.
Section 8 Remittance Advice	This section describes how to read and understand the contents of the Remittance Advice (RA) Statement for claims and adjustments, as well as a sample claim reconciliation method.
Section 9 HIPAA Requirements	This section presents an overview of the Health Insurance Portability and Accountability Act (HIPAA).
Appendix A	This section contains provider specific and/or service specific Billing Guides. Each Billing Guide provides comprehensive instruction on the proper completion of each block contained on the CMS-1500 Claim Form.
Appendix B	This section contains MA Bulletins applicable to each provider using this handbook.
Appendix C	This section contains instructions for Providers who will use the functions on the PA PROMISe™ Internet.
Appendix D	This section contains DPW forms and federally required forms along with instructions for proper completion.
Appendix E	This section contains the guidelines, procedures and standards for Federally Qualified Health Centers (FQHCs), their cost reporting instructions, worksheets, and settlement reports.
Appendix F	This section contains a crosswalk from previous MAMIS Provider Type to PROMISe™ Provider Types and Specialties.
Appendix G	This section contains a glossary of PA PROMISe™ terms, acronyms, and phrases with their definitions.

Last Modified: 03/04/2004

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