Attachment #1: New Provider Qualification Approval Template Provider Name: Provider Name
Dear: Provider Qualification Primary Contact Name,
Attached is your approved DP 1059, confirming that your organization is qualified to provide the service specialties listed 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 Your Endorsed Agreement: After ODP reviews the agreement, you will receive a date-stamped (endorsed) copy. This endorsed agreement must be included in your PROMISe® application.
- Submit Your PROMISe® Enrollment Application: Use the MA Program Online Provider Enrollment Application System,
- Submit your PROMISe® enrollment application.
- Submit the approved DP 1059
- Submit the endorsed ODP Waiver Provider Agreement
- Submit all required supporting documentation.
IMPORTANT DEADLINE: You must complete PROMISe® enrollment for your qualified specialty within 60 days of the date your DP 1059 was approved by your Assigned Administrative Entity. Failure to meet this deadline will invalidate your qualification and require you to restart the entire PAO process.
Ongoing Requirements
Newly qualified providers must:
• Participate in the Quality Assessment and Improvement (QA&I) process.
• Complete provider requalification in the fiscal year immediately following initial qualification.
• Providers delivering PCS and home health services must comply with the 21st Century CURES Act EVV requirement. This applies to Companion, In-Home and Community Support, Respite (in unlicensed settings), and Homemaker/Chore services. Click the link for more information on Electronic Visit Verification (EVV).
• Maintain compliance with all applicable ODP standards and regulatory requirements.
If your DP 1059 indicates that you were not approved for any service specialty, you may appeal that decision. To request a hearing, submit a written appeal within 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
Administrative Entity
cc: Regional PQ Lead
Central Office: ra-odpproviderenroll@pa.gov
