Carelon Health of Pennsylvania (HealthChoices Behavioral Health Program)

Carelon Health of Pennsylvania (HealthChoices Behavioral Health Program)  

Welcome, and thank you for joining our provider network. This page is your starting point for understanding our program, getting set up, and knowing where to go when you need help.  

This is the homepage for Carelon Health of Pennsylvania Medicaid providers.  

If you’re assisting a member outside PA Medicaid Behavioral Health, please use the contact information on the back of the member’s insurance card.  

Overall Steps to get started: 

1. If you are new to Pennsylvania’s HealthChoices Behavioral HealthChoices Program, review this resource Understanding-PA-Behavioral-Health-Health-Choices-Program.pptx  

2. Read the Carelon Provider Manual Provider Manual | Carelon Health of Pennsylvania  

3. Review your Provider Agreement, Exhibit A (Fee Schedule) and Covered Service Grid to know what is contractually required to be reimbursed. 

• Use only assigned procedure codes/modifiers  
• Cross reference the Covered Services Grid to know whether an authorization is required, the correct place of service, whether the service is Third Party Liability Exempt.   
• Share fee schedules and covered service grid with front desk, clinical and billing staff (and any updates thereafter).  

4. PA Department of Human Services PROMISe adherence Assign a team member to ensure you are always properly enrolled as a Medical Assistance provider.  

• PROMISe Provider Enrollment Webpage 
• Be sure to enroll according to your provider type and specialty code 
• If you are practitioner and a part of a group, the group must also be enrolled. 
• Know you must revalidate your enrollment every five years  

5. Provider Portals Claims Submission and More!  

For the best experience register for our Provider Portals Availity Essentials and Provider Connect and link accounts for easier access   

Availity Essentials	Availity Single Sign-On and New Features for Carelon Health of Pennsylvania Providers
Get Started – Register and Get Started with Availity Essentials	Availity Essentials Overview
Linking Your Provider Connect Account to Availity – For PA Individual and Group Practitioners

ProviderConnect Information and Resources

Login  Register  Demo

6. Review the information to help you and your staff succeed  

Provider Information | Carelon Health of Pennsylvania  

• Links to all relevant provider forms, medical necessity criteria, network information, newsletters, alerts etc. are at your fingertips  

7.  Attend an orientation group.   

• Orientation sessions are open to all providers, whether newly credentialed or already established in our network and even providers with single case agreements. Participation is encouraged for anyone who feels they would benefit from this knowledge. Sessions offer a good opportunity for new staff to orient themselves to Carelon and our processes. If you are interested in attending a provider orientation session, please request an invitation via PAMedicaidProviderRelations@Carelon.com  

8. Sign up to receive provider alerts and announcements  

• Sign up to Stay in Touch!  

9.  Review training resources for eligibility, authorizations, claims, and appeals.  

Provider Training | Carelon Health of Pennsylvania  

• Required Annual Trainings: Fraud Waste & Abuse and Cultural Competency (link above)   

Know who to contact when questions arise.