Attachment #1: New Provider Qualification Approval Template Provider Name: Provider Name
Dear: Provider Qualification Primary Contact Name,
Attached is your DP 1059, which confirms your qualification to provide specific services under the Consolidated, Community Living, and Person/Family Directed Support (P/FDS) Waivers.
Your Next Steps for Enrollment:
- Complete the ODP Waiver Provider Agreement: Follow the instructions provided in the cover letter to complete the ODP Waiver Provider Agreement.
- Receive Endorsed Agreement: Once completed, you will receive a date-stamped (endorsed) ODP Waiver Provider Agreement. This document will be used along with the DP 1059 form and other required materials.
- Submit Your PROMISe® Enrollment Application: Using the MA Program Online Provider Enrollment Application System, submit your PROMISe® enrollment application.
- Be sure to attach the approved DP 1059 form, the endorsed ODP Waiver Provider Agreement, and all other required supporting documentation.
Important: You must enroll your qualified specialty within 60 days of your approved DP 1059 from your Assigned Administrative Entity
NOTE: That new providers are required to complete the Quality Assessment and Improvement process and undergo requalification in the fiscal year immediately following their initial qualification. To ensure compliance, you must submit the PROMISe® enrollment application for your first service location within 60 days of receiving the approved DP 1059 form from your Assigned Administrative Entity.
If your DP 1059 indicates that you are not qualified to provide specific services under the Consolidated, Community Living, and Person/Family Directed Support (P/FDS) Waivers, you have the right to appeal this decision. To do so, you must submit a written request for a hearing within thirty-three (33) days of the date on this letter to:
Department of Human Services
Bureau of Hearings and Appeals
2330 Vartan Way Second Floor Harrisburg, PA 17110-9721
A copy of your appeal must be sent to:
Department of Human Services
Office of Developmental Programs Division of Program Management
P.O. Box 2675
Harrisburg, Pennsylvania 17105
For more information about your appeal rights and responsibilities, please refer to 55 Pa. Code Chapter 41, which covers Medical Assistance Provider Appeal Procedures. You can view the full text of Chapter 41 at: MA Provider Appeal Procedures.MA Provider Appeal Procedures
If you have any questions, please feel free to contact me at PQ AE Lead Contact Information.
Thank you.
Name of PQ AE Lead
cc: Regional PQ Lead Central Office: ra-odpproviderenroll@pa.gov
