Pennsylvania splits its payers in ways that catch practices off guard. Medicaid physical health runs through managed care plans that differ by region, while behavioral health is assigned to a separate county-based plan. Auto injury claims are capped at a percentage of Medicare. Workers’ compensation uses its own fee schedule, which no longer tracks current Medicare rates. And in 2026, the state employee plan moved to a new insurer. Maximum Billing handles medical billing for Pennsylvania physician practices and specialty groups, from Philadelphia and the Lehigh Valley to Harrisburg and Pittsburgh.
We bill in Pennsylvania and eleven other states. Schedule a consultation or call 800-820-0364.
Pennsylvania Medical Billing at a Glance
- Prompt pay: 45 days for clean claims, with 10% annual interest on late payments.
- Medicaid: PROMISe enrollment, revalidation at least every five years for each service location, and 180 days to file fee-for-service claims.
- Physical HealthChoices: mandatory Medicaid managed care in five zones, with different plans in each zone.
- Behavioral health: carved out to county-assigned behavioral health plans.
- Medicare: Novitas Solutions, Jurisdiction L.
- Auto injury claims: capped at 110% of the Medicare amount.
- Prior authorization: Act 146 deadlines for commercial and Medicaid managed care plans since January 1, 2024.
Prompt Pay Under Act 68
Pennsylvania’s Act 68 requires insurers, including Medical Assistance and CHIP managed care plans, to pay a clean claim within 45 days of receipt. Late payments earn 10% simple annual interest from the day after the payment was due, although insurers do not have to pay interest under $2. Act 146 of 2022 restated the 45-day rule. We track when every claim was received and paid, so late payments are noticed and the interest is not left behind.
Pennsylvania Medical Assistance
- Enrollment and revalidation: providers enroll through PROMISe and must revalidate at least every five years. Each service location has its own revalidation date and needs its own full application, which should be submitted at least 60 days before that date.
- Timely filing: fee-for-service claims are due within 180 days of the date of service. Rejected claims can be resubmitted, and adjustments filed, up to 365 days. Managed care plans set their own limits in their contracts.
- Physical HealthChoices: mandatory managed care in five zones: Southeast, Southwest, Lehigh/Capital, Northeast, and Northwest. Geisinger Health Plan, Jefferson Health Plans, and UPMC for You are in every zone. AmeriHealth Caritas, Highmark Wholecare, Keystone First, and UnitedHealthcare Community Plan are in some zones only.
- Behavioral health carve-out: mental health and substance use services are managed by behavioral health managed care organizations assigned by the member’s county, not by the physical health plan.
- Community HealthChoices: a separate managed care program covering physical health and long-term services for people with both Medicare and Medicaid and for adults with physical disabilities.
A practice in more than one zone, or near a zone boundary, can need contracts with several plans to see the same kind of patient. Each location’s revalidation date also has to be tracked on its own.
Medicare and Medicare Advantage
Original Medicare claims in Pennsylvania go to Novitas Solutions, the Medicare Administrative Contractor for Jurisdiction L, which also covers New Jersey, Delaware, Maryland, and the District of Columbia. Many Pennsylvania Medicare patients are enrolled in Medicare Advantage plans, so a patient’s Medicare card often does not tell you who will actually pay. Each Medicare Advantage plan has its own network, authorization rules, and fee schedule, and we verify the plan before every visit.
Commercial Plans, PEBTF, and Pennie
Pennsylvania’s commercial market includes Highmark, Independence Blue Cross, Capital Blue Cross, UPMC Health Plan, Geisinger, and national carriers. Pennie is the state’s insurance exchange, and fifteen insurers offer individual-market plans in 2026.
One change matters for 2026: starting January 1, 2026, the Pennsylvania Employees Benefit Trust Fund moved its medical plans for Commonwealth employees to Aetna, and Geisinger Health Plan is no longer offered to them. Claims for these patients billed to their old plan will deny, so their coverage needs to be verified again.
Prior Authorization Under Act 146
Since January 1, 2024, Act 146 of 2022 has set prior authorization deadlines for commercial insurers and Medical Assistance and CHIP managed care plans: 72 hours for urgent requests and 15 days for non-urgent requests. Denials must be made by a reviewer in the same or a similar specialty, and plans must publish the services that need authorization. Act 146 also requires 60 days of continuity of care for new enrollees and when a provider leaves a network. We track each request against those deadlines and follow up when a plan runs past them.
Auto Injury and Workers’ Compensation Claims
- Auto (first-party medical benefits): under the Motor Vehicle Financial Responsibility Law, a provider may not accept more than 110% of the Medicare amount or its usual charge, whichever is less. Where Medicare has no rate, the cap is 80% of the usual and customary charge. Benefits are overdue 30 days after the insurer receives reasonable proof, and overdue benefits earn 12% interest. Insurers can send bills to a peer review organization, and providers can ask for reconsideration within 30 days of its decision.
- Workers’ compensation: fees are capped at 113% of the 1994 Medicare rate, updated through the state’s own rules rather than current Medicare. The caps apply whether or not the provider takes Medicare. Bills go on the CMS-1500 or UB-04, and the insurer must pay within 30 days of receiving the bill and medical report.
Credentialing Pennsylvania Physicians
Pennsylvania does not currently set a deadline for insurers to finish credentialing or require provisional payment while it is pending. A bill to add credentialing deadlines was introduced in 2025 but has not become law. The time a new physician spends waiting is time their claims may not pay at in-network rates. Starting early and submitting complete applications matter more here than in states with a legal deadline.
We handle CAQH profiles, Medicare enrollment through PECOS, PROMISe enrollment and revalidation, and HealthChoices and commercial plan applications. See our medical credentialing services, our Pennsylvania Medicaid provider enrollment guide, and, for practices with several clinicians, our group practice billing services.
Where Pennsylvania Medical Claims Go Wrong
- Claims sent to the wrong HealthChoices plan for the patient’s zone.
- Behavioral health services billed to the physical health plan instead of the county’s behavioral health plan.
- A location’s Medical Assistance enrollment lapsing because its revalidation date was missed.
- Auto claims billed above the 110% Medicare cap, or never followed up after a peer review referral.
- State employee patients still billed to their 2025 plan.
- Late payments never checked for Act 68 interest.
Our claims denial management and accounts receivable management pages describe how we handle each of these.
What Our Pennsylvania Medical Billing Includes
- Eligibility and benefits checks for commercial, PEBTF, HealthChoices, Medicare, and Medicare Advantage patients.
- Prior authorization tracking against Act 146 deadlines.
- Charge entry and coding checks before each claim goes out.
- Payment posting that flags Act 68 interest due and underpaid claims.
- Denial follow-up and appeals.
- Credentialing, PROMISe revalidation, and enrollment updates for every clinician and location.
We work in your existing practice management system. Before any patient data changes hands, we sign a Business Associate Agreement, and each member of our team completes HIPAA certification. Across our clients in 2026, the clean claim rate is 91%, and accounts receivable average 34 days.
Pennsylvania mental health practices can see our Pennsylvania behavioral health billing page. For practices in our other states, see our national medical billing services page.
Frequently Asked Questions
How fast do Pennsylvania insurers have to pay a clean claim?
Within 45 days of receipt under Act 68, with 10% annual interest on late payments.
What is the timely filing limit for Pennsylvania Medicaid?
180 days from the date of service for fee-for-service claims. HealthChoices managed care plans set their own limits in their provider contracts.
How much can we bill for an auto accident patient in Pennsylvania?
No more than 110% of the Medicare amount or your usual charge, whichever is less, under the Motor Vehicle Financial Responsibility Law.
Does Pennsylvania have a credentialing deadline for insurers?
Not currently. A bill proposing deadlines was introduced in 2025 but has not passed.
Start With a Pennsylvania Billing Review
If HealthChoices plans, revalidation dates, or auto claims are costing your practice money, send us a recent aging report and a sample of denials, and we will go through them with you. Contact us or call 800-820-0364.