What is Community HealthChoices (CHC)?

Community HealthChoices (CHC) is Pennsylvania's mandatory managed care program for dually eligible individuals and individuals with physical disabilities. It serves people in communities, giving them the opportunity to work, spend more time with their families, and experience an overall better quality of life.

CHC uses managed care organizations to coordinate physical health care and long-term services and supports (LTSS) for individuals who are:

• 21 years of age and older who are dually eligible for Medicare and Medicaid
• Qualify for Medicaid long-term services and supports (LTSS) because they need the level of care provided by a nursing facility

Verifying Eligibility

Participant eligibility is subject to change. Providers must verify eligibility before every service is rendered, using one of the following methods:

• PA Health & Wellness Secure Provider Portal
• PHW's Automated Participant Eligibility (IVR) system
• Speaking to a PHW Provider Services Representative: 1-844-626-6813
• The State's PROMISe system

Long-Term Services and Supports (LTSS)

When a PHW CHC Participant (PTP) is nursing facility clinically eligible (NFCE) and qualifies for LTSS, PHW meets with the Participant to assess their needs through a comprehensive needs assessment. The Participant will receive a Service Coordinator who will create a Person-Centered Service Plan (PCSP).

LTSS includes services in the community and in nursing homes or other institutions to help Participants live where they want and support where they want to work.

Comprehensive Needs Assessment Timeframes

Role of the Service Coordinator (SC)

• Works with the Participant to create and maintain the PCSP
• Helps Participants access both LTSS and other covered and non-covered medical, social, housing, and educational services
• Providers must work with the SC to ensure continuity of the Participant's needs

Person-Centered Service Plan (PCSP)

The PCSP is a written plan addressing:

• How the Participant's physical, cognitive, and behavioral health needs will be managed
• How the Participant's LTSS needs will be coordinated

EVV Compliance Requirements (Effective January 1, 2025)

PHW requires Personal Care Service (PCS) and Home Health Care Service (HHCS) Providers to achieve a minimum of 85% EVV compliance on a quarterly basis.

• PHW collects data and monitors the EVV system for unconfirmed visits and missed services
• Providers performing at or below 85% for two consecutive quarters will face a formal review requiring corrective action

EVV is used to verify service visits — ensuring that authorized care was delivered at the right time, place, and by the right provider.

Making Referrals

Appropriate referrals for Mental Health, Drug, Alcohol, and Substance Abuse Services for participants can be made by calling:

Mandated Reporting

If you suspect abuse, do not ignore it. You are a mandated reporter. Contact the appropriate helpline immediately.

Submitting Prior Authorization Requests

Submit Prior Authorization requests through the Secure Provider Web Portal:

Other Submission Methods

• Call the Medical Management Department: 1-844-626-6813
• Fax using the Prior Authorization fax forms (available on pahealthwellness.com)

Questions About Authorizations

• Phone: 1-844-626-6813
• Email: authorizations_pa@pahealthwellness.com
• Secure message in HHAeXchange

Definition of Medically Necessary

A service is considered Medically Necessary if it meets one or more of the following standards:

• Will, or is reasonably expected to, prevent the onset of an illness, injury, condition, or disability
• Will or is reasonably expected to reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, or disability
• Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities
• Will provide the opportunity for a Participant receiving LTSS to have access to the benefits of community living, achieve person-centered goals, and live and work in the setting of their choice

PHW's administrative processes include but are not limited to:

• Coordination of Benefits
• Timely filing
• Authorizations
• Identification and referral for mental health, drug, alcohol, and substance use services
• PHW's Lock-In Program
• Encounter Data reporting

Coordination of Benefits

• Providers do not need to obtain prior approval from PHW for Medicare-covered services
• If PHW becomes the primary payer (non-covered service, benefits exhausted, etc.), prior authorization must be obtained timely from PHW
• Any other insurance, including Medicare, is always primary to Medicaid coverage

• Providers should voluntarily disclose overpayments or improper payments of MA funds
• The Provider Self Audit Protocol is available at: dhs.pa.gov — Provider Self Audit Protocol
• Providers are expected to make books, records, etc. timely accessible to: the PA Office of Attorney General Medicaid Fraud Control Section, HHS OIG, and Comptroller General

Network Providers are prohibited from intentionally segregating or discriminating against Participants in any way on the basis of:

• Race, color, creed, sex, religion, age, national origin, ancestry
• Marital status, sexual orientation, gender identity, language
• MA status, income status, program participation, health status
• Disease or pre-existing condition, anticipated need for healthcare
• Physical or mental disability (except where medically indicated)

• PA Health & Wellness follows accessibility requirements set forth by applicable regulatory and accrediting agencies
• PHW monitors compliance with these standards annually
• Providers are required to comply with Americans with Disabilities Act (ADA) accessibility guidelines
• Providers should make efforts to provide accommodations such as large print materials and easily accessible doorways

Cultural Competency Defined

Cultural Competency is the willingness and ability of a system to value the importance of culture in the delivery of services to all segments of the population. It is developmental, community focused, and family oriented.

PHW is committed to helping each Provider demonstrate:

• Cultural Competency
• Linguistic Competency
• Disability Competency

What is Dementia?

• Dementia is not one single disease
• Dementia is not a normal part of aging
• "Dementia" literally means "away from mind" — it describes a group of symptoms and behaviors affecting thinking, emotions, and behavior
• Many types are progressive and irreversible
• Dementia is caused by damage to brain cells; how the damage occurs differs by type

Who Can File a Complaint or Grievance?

• The Participant
• The Participant's designated authorized representative
• The Participant's Provider with written authorization from the participant

PHW Complaint and Grievance Unit

What Are Critical Incidents?

Critical Incidents are events that compromise the Participant's health or welfare, including:

• Death (other than by natural causes)
• Serious injury resulting in emergency room visits, hospitalizations, or death
• Hospitalization (except planned hospital stays)
• Provider or staff misconduct (deliberate, willful, unlawful, or dishonest activities)
• Abuse, Neglect, Seclusion, Exploitation, Restraint
• Service interruption
• Medication errors

Quality Improvement Program (QIP)

Scope: Addresses the quality of clinical care and services provided to PHW Participants.

Provider's Role: Providers and practitioners are required to cooperate with Quality Improvement (QI) activities and allow PHW to use their performance data.

The QI Department uses PIPs, focused studies, and other QI initiatives to identify improvement opportunities. Current PIPs include Strengthening Care Coordination and Nursing Home Transitions.

The HEDIS® (Healthcare Effectiveness Data and Information Set) is the primary measure set used in QI activities.

PHW hosts two webinars annually (late spring and fall) to present and discuss issues identified through Provider Relations, Provider Services, or the Quality Management Process.

Key Plan Contact Information

Office Disaster Management Plan

A formal strategy outlining steps for preventing, responding to, and recovering from emergencies. It should cover:

• Risk assessment
• Clear communication protocols (emergency contacts, mass notifications)
• Defined roles for a response team
• Detailed evacuation procedures (routes, assembly points, essential personnel)
• IT recovery for data and systems
• Post-disaster business continuity to restore operations

Plans should be documented, approved, and regularly tested.

Where to Find Emergency Info

• Ready.PA.gov — PA official emergency preparedness hub
• PA DHS/Aging — Guidance for older adults and those with medical needs
• PEMA — Pennsylvania Emergency Management Agency
• FEMA — Federal agency; FEMA app provides alerts