Attachment #3: New Provider Qualification Not Approved Template Applicant Name: Applicant Name

Dear: Provider Qualification Primary Contact Name,

The Assigned AE Entity Name completed a review of the ODP New Provider Self-Assessment Tool, the ODP Provider Qualification Form DP 1059, the Provider Qualification Documentation Record, and all supporting documentation as of Effective Date AE Completed Review. A communication requesting additional information was sent on Date Letter Sent.

This letter serves as notification that the ODP Provider Qualification Form DP 1059 and the supporting documentation received on Date of Receipt are not approved due to:

• Lack of sufficient information.

• Failure to submit the required qualification documentation within the 60-day timeframe.

• Failure to complete the qualification process within the 120-day timeframe.

• Failure to meet the qualification requirements outlined in the Consolidated, Community Living, and Person/Family Directed Support (P/FDS) Waiver services.

The Medical Assistance (MA) Program Online Provider Enrollment Application will not be processed without an approved DP 1059. To be reconsidered as a provider for ODP and eligible to render waiver services, you must re-register for Provider Applicant Orientation (PAO) through the Department of Human Services (DHS) website.

NOTE:  If a provider applicant is determined “Not Approved,” they must wait 365 days from the date of their most recent full-day PAO session before retaking the ODP Provider Applicant Orientation curriculum.   

If you disagree with the determination that you are not qualified to provide services through the Consolidated, Community Living, and/or P/FDS Waivers, you may appeal this decision by submitting a written request for a hearing within thirty-three (33) days of the date of this letter to:

Department of Human Services

Bureau of Hearings and Appeals

2330 Vartan Way Second Floor Harrisburg, PA 17110-9721

Send a copy of your appeal 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.

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

      ODP Central Office: ra-odpproviderenroll@pa.gov