Requirements for Provider Type 31 - Physician

1 04/01/2017 1 Requirements for Provider Type 31 - Physician specialty Code and Provider Eligibility Program (PEP) The chart below lists all PT 31 specialties and the PEPs that may be associated with each specialty code. Please select the Provider s specialty from this list and associate it with an appropriate PEP. specialty SUBSPECIALTY Eligible PEPs 220 - Hearing Aid Dispenser Fee-for-Service (FFS) 301 Med and Osteopathic Trainee Enrollment Not Paid only (ENP) 310 Allergy & Immunology FFS, ENP 310 Allergy & Immunology 108 Clinical & Laboratory Immunology FFS, ENP 311 Anesthesiology FFS, ENP 311 Anesthesiology 113 Critical Care Medicine FFS, ENP 311 Anesthesiology 145 Pain Management FFS, ENP 314 Dermatology FFS, ENP 314 Dermatology 115 Dermatological Immunization FFS, ENP 314 Dermatology 116 Dermatopathology FFS, ENP 315 Emergency Medicine FFS, ENP 315 Emergency Medicine 136 Medical Toxicology FFS, ENP 315 Emergency Medicine 148 Pediatric Emergency Medicine FFS, ENP 315 Emergency Medicine 169 Sports Medicine FFS, ENP 316 Family Practice FFS, ENP, Healthy Beginnings + (HBP)

2 316 Family Practice 125 Geriatric Medicine FFS, ENP, HBP 316 Family Practice 169 Sports Medicine FFS, ENP, HBP 318 General Practitioner FFS, ENP 319 Surgery FFS, ENP 319 Surgery 105 Cardiovascular Surgery FFS, ENP 319 Surgery 111 Colon and Rectal Surgery FFS, ENP 319 Surgery 124 General Surgeon FFS, ENP 319 Surgery 139 Neurological Surgery FFS, ENP 319 Surgery 160 Pediatric Surgery FFS, ENP 319 Surgery 170 Surgery of the Hand FFS, ENP 319 Surgery 171 Surgical Critical Care FFS, ENP 319 Surgery 172 Thoracic Surgery FFS, ENP 319 Surgery 174 Vascular Surgery FFS, ENP 322 Internal Medicine FFS, ENP 322 Internal Medicine 102 Adolescent Medicine FFS, ENP 322 Internal Medicine 104 Cardiovascular Disease FFS, ENP 322 Internal Medicine 108 Clinical and Laboratory Immunology FFS, ENP 322 Internal Medicine 109 Clinical Cardiac Electrophysiology FFS, ENP 322 Internal Medicine 113 Critical Care Medicine FFS, ENP 322 Internal Medicine 118 Endocrinology, Diabetes & Metabolism FFS, ENP 322 Internal Medicine 122 Gastroenterology FFS, ENP 322 Internal Medicine 125 Geriatric Medicine FFS, ENP 322 Internal Medicine 130 Hematology/Oncology FFS, ENP 322 Internal Medicine 132 Infectious Disease FFS, ENP 322 Internal Medicine 133 Interventional Cardiology FFS, ENP 322 Internal Medicine 138 Nephrology FFS, ENP 322 Internal Medicine 162 Proctology FFS, ENP 322 Internal Medicine 163 Pulmonary Disease FFS, ENP 322 Internal Medicine 167 Rheumatology FFS, ENP 322 Internal Medicine 169 Sports Medicine FFS, ENP 328 -- Obstetrics & Gynecology FFS, ENP, HBP 328 Obstetrics & Gynecology 113 Critical Care Medicine FFS, ENP.

3 HBP 328 Obstetrics & Gynecology 127 Gynecologic Oncology FFS, ENP, HBP 04/01/2017 2 specialty SUBSPECIALTY Eligible PEPs 328 Obstetrics & Gynecology 134 - Maternal and Fetal Medicine FFS, ENP, HBP 328 Obstetrics & Gynecology 165 Reproductive Endocrinology FFS, ENP, HBP 330 Ophthalmologist FFS, ENP 330 Ophthalmologist 112 Cornea Ophthalmology FFS, ENP 330 Ophthalmologist 117 Diabetes Ophthalmology FFS, ENP 330 Ophthalmologist 121 Glaucoma Ophthalmology FFS, ENP 330 Ophthalmologist 123 General Ophthalmology FFS, ENP 330 Ophthalmologist 154 Pediatric Ophthalmology FFS, ENP 330 Ophthalmologist 164 Refractory Ophthalmology FFS, ENP 330 Ophthalmologist 166 Retina Ophthalmology FFS, ENP 331 Orthopedic Surgery FFS, ENP 331 Orthopedic Surgery 128 Hand Surgery FFS, ENP 332 Otolaryngology FFS, ENP 332 Otolaryngology 144 Otology/Neurotology FFS, ENP 332 Otolaryngology 155 Pediatric Otolaryngology FFS, ENP 332 Otolaryngology 161 Plastic Surgery within the Head FFS, ENP 333 Pathology FFS, ENP 333 Pathology 103 Blood Banking/Transfusion Medicine FFS, ENP 333 Pathology 106 Chemical Pathology FFS, ENP 333 Pathology 114 Cytopathology FFS, ENP 333 Pathology 116 Dermatopathology FFS, ENP 333 Pathology 119 Forensic Pathology FFS, ENP 333 Pathology 129 Hematology FFS, ENP 333 Pathology 131 Immunopathology FFS, ENP 333 Pathology 135 Medical Microbiology FFS, ENP 333 Pathology 141 Neuropathology FFS, ENP 333 Pathology 156 Pediatric Pathology FFS, ENP 336 Physical Medicine & Rehabilitation FFS, ENP 336 Physical Medicine & Rehabilitation 145 Pain Management FFS.

4 ENP 336 Physical Medicine & Rehabilitation 168 Spinal Cord Injury Medicine FFS, ENP 337 Plastic Surgery FFS, ENP 337 Plastic Surgery 170 Surgery of the Hand FFS, ENP 338 - Neurology FFS, ENP 339 Psychiatry FFS, ENP, EPOMS 339 Psychiatry 101 Addiction Psychiatry FFS, ENP, EPOMS 339 Psychiatry 107 Child and Adolescent Psychiatry FFS, ENP, EPOMS 339 Psychiatry 110 Clinical Neurophysiology FFS, ENP, EPOMS 339 Psychiatry 120 Forensic Psychiatry FFS, ENP, EPOMS 339 Psychiatry 126 Geriatric Psychiatry FFS, ENP, EPOMS 339 Psychiatry 145 Pain Management FFS, ENP, EPOMS 341 Radiology 180 Radiation Oncologist FFS, ENP 341 Radiology 142 Neuroradiology FFS, ENP 341 Radiology 143 Nuclear Radiology FFS, ENP 341 Radiology 158 Pediatric Radiology FFS, ENP 341 Radiology 173 Vascular & Interventional Radiology FFS, ENP 342 Preventive Medicine FFS, ENP 342 Preventive Medicine 136 Medical Toxicology FFS, ENP 342 Preventive Medicine 175 Aerospace Medicine FFS, ENP 342 Preventive Medicine 177 Occupational Medicine FFS, ENP 342 Preventive Medicine 178 Public Health/General Preventive FFS, ENP 342 Preventive Medicine 179 Under Sea and Hyperbaric Medicine FFS, ENP 343 Urologist FFS, ENP 345 Pediatrics FFS, ENP 345 Pediatrics 102 Adolescent Medicine FFS, ENP 345 Pediatrics 108 Clinical and Laboratory Immunology FFS, ENP 04/01/2017 3 specialty SUBSPECIALTY Eligible PEPs 345 Pediatrics 136 Medical Toxicology FFS, ENP 345 Pediatrics 137 Neonatal-Perinatal Medicine FFS, ENP 345 Pediatrics 146 Pediatric Cardiology FFS, ENP 345 Pediatrics 147 Pediatric Critical Care Medicine FFS, ENP 345 Pediatrics 148 Pediatric Emergency Medicine FFS.

5 ENP 345 Pediatrics 149 Pediatric Endocrinology FFS, ENP 345 Pediatrics 150 Pediatric Gastroenterology FFS, ENP 345 Pediatrics 151 Pediatric Hematology-Oncology FFS, ENP 345 Pediatrics 152 Pediatric Infectious Disease FFS, ENP 345 Pediatrics 153 Pediatric Nephrology FFS, ENP 345 Pediatrics 157 Pediatric Pulmonary FFS, ENP 345 Pediatrics 159 Pediatric Rheumatology FFS, ENP 345 Pediatrics 169 Sports Medicine FFS, ENP 370 Tobacco Cessation FFS, ENP 426 Autism Certified Psychologist ENP, Adult Autism Waiver 548 Therapeutic Staff Support FFS, ENP, EPOMS 549 Mobile Therapy FFS, ENP, EPOMS 558 Behavior Specialist for Children with Autism FFS, ENP, EPOMS 559 Behavioral Specialist Consultant FFS, ENP, EPOMS 574 Pre-school E. I. Service FFS, ENP 04/01/2017 4 Required Documents for an Individual Provider Type 31: The following documents and supporting information are required by the Bureau of Fee-For-Service Programs to enroll as a Provider Type 31 (please make sure all documents are legible): Completed application for an Individual Provider application must include: o Signed Provider Agreement with an original Provider signature.

6 And o Completed Ownership or Control Interest Disclosure form If the Provider is not a citizen of the United States, submit copy of Permanent Resident Card or Form I-797 showing authorization to work in the United States Copy of license issued by Department of State Copy of DEA certificate Copy of Board Certification, if applicable Copy of Mammography Certificate, if applicable Diabetes Training Certificate, if applicable Certificate of Completion for Application of Topical Fluoride Varnish, if applicable Copy of your PA Clinical Laboratory Permit and Clinical Laboratory Improvement Amendments (CLIA) Certificate, if applicant performs laboratory services o Note: BOTH In-State and Out-of-State Providers must submit a PA Department of Health-issued clinical lab permit if Provider seeks to bill for laboratory services If an Out-of-State Provider , proof of current home state Medicaid Participation Required Documents for a Provider Type 31 Group: Completed application for a Group Provider the application must include: o A signed copy of Provider Agreement with original signature of authorized representative; and o Copy of Ownership or Control Interest Disclosure form Documentation generated by the IRS, showing both the Provider s legal name and FEIN documentation must come from the IRS.

7 This Department does not accept W-9s If the application is for an Out-of-State Provider , submit proof of current home state Medicaid participation If the Group operates under a fictitious name, submit a copy of the D/B/A filing with Department of State Corporation Bureau Copy of Corporation paperwork issued by Department of State Corporation Bureau or business partnership agreement If Group is tax-exempt, submit IRS 501 (c)(3) letter confirming that status Physicians (31) are encouraged to apply online via our Electronic Provider Portal at . If circumstances do not allow online submission, send application and required documents to: DHS Provider Enrollment PO Box 8045 Harrisburg, PA 17105-8045 Fax: (717) 265-8284 E-mail.