Pennsylvania Medical Billing Services

Running a medical practice in Pennsylvania requires precise handling of state-specific Medicaid regulations, insurer claim protocols, and frequent updates from both public and private payers. Providers across Philadelphia, Pittsburgh, Harrisburg, Allentown, and Erie operate under the Pennsylvania Department of Human Services (DHS) Medical Assistance (MA) Program, which sets detailed standards for documentation, coding, and reimbursement timelines.

MZ Medical Billing Services manages the full revenue cycle for healthcare organizations throughout Pennsylvania. Our billing team oversees coding accuracy, charge capture, claim submission, payment posting, and accounts receivable follow-up with strict adherence to DHS and CMS requirements.

We work directly with major Pennsylvania payers, including Highmark Blue Shield, Independence Blue Cross, Geisinger Health Plan, UPMC Health Plan, Aetna, Cigna, Humana, and Pennsylvania Medicaid (MA). Each claim is reviewed against payer-specific rules and compliance criteria to prevent denials and maintain consistent reimbursement.

Our internal audits identify documentation errors, missing modifiers, and underpaid claims before they affect cash flow. Denials are analyzed and appealed promptly, while aging receivables are closely tracked to improve recovery rates.

MZ Medical Billing Services clients in Pennsylvania consistently achieve strong revenue outcomes. On average, our clients reach a 98% claim approval rate, a 97% first-pass resolution rate, and maintain an average of less than 30 days in accounts receivable. These results reflect the effectiveness of accurate coding, documentation integrity, and adherence to payer compliance standards in Pennsylvania’s healthcare billing environment.

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98%
Claim Approval Rate

97%
First pass Ratio

<30
Days in AR

96%
Collection Ratio

Outsourcing Medical Billing in Pennsylvania with MZ Medical Billing

Outsourcing to MZ Medical Billing gives Pennsylvania healthcare providers access to a dedicated team that manages every part of the revenue cycle with precision and full regulatory compliance. Our certified billing professionals handle claim submission, payment posting, denial resolution, and accounts receivable recovery for organizations of all sizes, from independent physician practices to large hospital-affiliated networks.

As Pennsylvania’s healthcare system continues to grow across hospitals, outpatient centers, rural clinics, and telehealth practices, outsourcing medical billing has become critical to maintaining consistent cash flow and reducing administrative overhead. MZ Medical Billing provides transparent reporting, detailed performance metrics, and scalable billing support that adjusts to your organization’s size and service mix while you focus on patient care.

Pennsylvania providers face significant reimbursement and compliance challenges due to state and federal audit programs. The Pennsylvania Department of Human Services (DHS) conducts Medical Assistance (MA) compliance audits and Recovery Audit Contractor (RAC) reviews to identify overpayments and improper billing. These reviews can result in repayment demands or reimbursement delays when documentation or coding does not meet DHS and CMS requirements.

Additionally, Pennsylvania Medicaid (MA) frequently updates its provider handbooks, billing codes, and fee schedules, including changes to physician services, outpatient hospital care, and behavioral health programs. Providers that fail to incorporate these updates into their billing systems risk denials, reduced payments, or audit findings.

By outsourcing your billing to MZ Medical Billing, you reduce compliance risks, prevent underpayments, and keep your billing operations aligned with Pennsylvania Medicaid (MA), Medicare, and major commercial payer requirements. Our experienced billing team helps providers maintain financial accuracy and predictable cash flow across all specialties.

Our clients typically achieve a 20–30% reduction in claim denials, 10–15% faster reimbursements, and up to a 25% improvement in overall collections, reflecting the accuracy, compliance, and performance discipline our team brings to every stage of the revenue cycle.

Leading Medical Billing Company in Pennsylvania

MZ Medical Billing stands out among Pennsylvania’s medical billing providers, focused on strengthening your practice’s revenue cycle through precision, compliance, and measurable accountability. We operate as a full-service billing partner, managing every stage of the billing process to minimize denials, accelerate reimbursements, and improve financial outcomes for practices across the state.

Transforming Your Revenue Cycle

We manage billing operations built around accuracy, regulatory compliance, and timely reimbursements—helping practices maintain strong cash flow while reducing administrative workload. Our process includes pre-submission audits, structured claim workflows, and denial management systems that protect revenue and align with Pennsylvania Medicaid (Medical Assistance) and commercial payer requirements.

Comprehensive End-to-End Solutions

Our Pennsylvania medical billing services cover the full revenue cycle: patient registration, insurance verification, coding, claim submission, payment posting, denial resolution, and A/R recovery. Every phase follows Pennsylvania Department of Human Services (DHS) and CMS guidelines, incorporating payer-specific claim rules from both public and private insurers.

Proactive Compliance Monitoring

Our billing team continuously monitors updates from the Pennsylvania DHS, managed-care plan revisions, and policy changes from CMS and commercial payers. Whenever fee schedules, code sets, or audit requirements change, we adjust our workflows immediately—helping practices prevent compliance risks and payment delays.

Deep Understanding of Pennsylvania’s Billing & Audit Environment

Pennsylvania Medicaid (Medical Assistance) operates under multiple oversight programs designed to monitor payment integrity and compliance. The Pennsylvania DHS conducts Recovery Audit Contractor (RAC) reviews and Medical Assistance compliance audits to identify overpayments and improper billing, often using multi-year review periods that can affect provider reimbursements.

The state also participates in the Payment Error Rate Measurement (PERM) program, which tracks improper payments across Medicaid and CHIP claims. These initiatives make billing accuracy, documentation integrity, and audit readiness essential for every Pennsylvania provider.

Personalized Approach

Every Pennsylvania practice operates with a different payer mix, specialty profile, and workflow structure. We customize our billing strategy to your operational needs while maintaining strict accuracy, compliance, and reporting standards that align with both Medicaid and commercial payer requirements.

Dedication to Accuracy

Before claims are submitted, our certified billing team reviews documentation and coding to confirm compliance with payer and federal guidelines. We identify potential coding inconsistencies and documentation gaps early, reducing denials and improving turnaround times on payments.

What We Offer

Pennsylvania Medical Billing Services We Offer

MZ Medical Billing provides complete revenue cycle management for healthcare providers throughout Pennsylvania, designed to improve billing accuracy, maintain compliance with Pennsylvania Department of Human Services (DHS) Medical Assistance (MA) rules, and sustain predictable reimbursements. Each service focuses on reducing denials, closing documentation gaps, and strengthening compliance across both Medicaid and commercial payer claims.

Our certified billing specialists hold credentials from AAPC, AHIMA, and HBMA, with direct experience in Pennsylvania Medicaid (MA), managed care organizations (MCOs), and multi-payer billing systems. We support hospitals, outpatient centers, telehealth providers, and specialty practices across Philadelphia, Pittsburgh, Harrisburg, Allentown, and Erie.

Revenue Cycle Management (RCM)

We oversee the full billing process, from charge capture and eligibility verification to payment posting and performance reporting, while following DHS and CMS regulations. Our focus is on maintaining consistent cash flow, reducing administrative rework, and improving overall billing accuracy.

Appeals and Disputes Management

Our appeals team reviews rejected and underpaid claims using verified payer rules and Pennsylvania Medicaid (MA) guidance. Each appeal includes supporting documentation, coding references, and submission proof to recover revenue and resolve payer discrepancies efficiently.

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Denial Management

We track, categorize, and analyze denial trends such as missing authorizations, incomplete documentation, or incorrect modifiers. Root causes are addressed directly in your billing workflow to increase first-pass approval rates and minimize recurring denials.

Referral and Authorization Management

Authorizations are obtained and monitored for inpatient, outpatient, and specialty services throughout Pennsylvania. Each referral and prior approval is recorded and verified to prevent service interruptions and reduce nonpayment risks.

Medical Coding Services

Our certified CPC and CCS coders assign ICD-10-CM, CPT, and HCPCS Level II codes accurately under Pennsylvania Medicaid (MA), Medicare, and commercial payer rules. Documentation is reviewed for accuracy and compliance before claim submission to prevent denials and audit findings.

Insurance Verification Services

Before each patient visit, eligibility and benefits are verified for Medicaid and commercial plans. Deductibles, copays, and coverage details are confirmed to minimize rework, prevent claim delays, and improve patient billing transparency.

Payment Posting

All insurance and patient payments are posted daily with ERA reconciliation. Underpayments, payer adjustments, and duplicate entries are identified and corrected promptly to keep Pennsylvania practice ledgers accurate and up to date.

Patient Billing Services

We manage patient statements and inquiries in accordance with Pennsylvania billing and balance billing regulations. Each statement is clear, itemized, and easy to understand, improving collection efficiency and reducing administrative workload for front office teams.

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Old AR Cleanup

Aged accounts are reviewed and categorized to identify unbilled, denied, or unresolved claims. Our Pennsylvania A/R specialists reprocess eligible claims and close outdated accounts to recover lost or delayed revenue.

Medical Billing Write-Offs Recovery

All historical write-offs are audited for payer and contract compliance. When recoverable discrepancies are found, claims are corrected and resubmitted to restore income that was previously written off.

Accounts Receivable (AR) Recovery

Accounts aging beyond 30, 60, and 90+ days are prioritized for systematic follow-up. Our billing team works directly with Pennsylvania Medicaid (MA), managed care organizations, and commercial payers to maintain stable collections and continuous cash flow.

Claims Submission

Every claim undergoes a detailed compliance and accuracy review, including coding, modifiers, documentation, and payer data, before submission through clearinghouses. Our process aligns with Pennsylvania Medicaid (MA) and Medicare standards, resulting in faster acceptance rates and fewer rejections.

Common Problems Pennsylvania Providers Face in Medical Billing

Complex Medicaid and Managed Care Requirements

Providers across Pennsylvania manage multiple payer systems, including Pennsylvania Medicaid (Medical Assistance), Highmark Blue Shield, UPMC Health Plan, Independence Blue Cross, Geisinger Health Plan, and Aetna Better Health. Each payer follows its own claim format, authorization rules, and documentation criteria. Missing or misaligned data fields lead to denials, rework, and delayed reimbursements that directly affect practice revenue.

Ongoing Medicaid and MCO Policy Changes

The Pennsylvania Department of Human Services (DHS) and Managed Care Organizations (MCOs) release frequent updates to billing manuals, provider handbooks, and fee schedules. When practices continue using outdated codes or claim formats, payments are delayed, reduced, or flagged for audit review.

Prior Authorization and Documentation Gaps

Authorization errors, missing medical necessity documentation, and mismatched CPT or ICD-10 codes are common across Pennsylvania. Behavioral health, therapy, and diagnostic imaging providers face higher denial rates when pre-approvals are incomplete or expired.

Dual Eligibility and Coordination of Benefits Errors

Many patients qualify for both Medicare and Medicaid, creating sequencing challenges between primary and secondary payers. When claims are filed in the wrong order or COB information is missing, payers return or suspend claims, creating avoidable cash flow interruptions.

Aging Accounts Receivable and Unresolved Denials

Unstructured A/R management and limited denial tracking cause long payment delays. Claims older than 60 or 90 days often remain unworked, and small payment discrepancies go unnoticed. Over time, these gaps result in significant, preventable revenue loss.

Technical and Portal Submission Issues

The PROMISe™ portal and MCO submission systems use strict file formats, data validation rules, and provider ID structures. Errors in file transmission or missing claim attachments often trigger rejections. Many small and mid-sized practices lack in-house staff who can quickly identify and correct these issues.

How MZ Medical Billing Solves These Challenges in Pennsylvania

Direct Experience with Pennsylvania Medicaid and MCO Systems

Our billing team works daily in the PROMISe™ portal, MCO platforms, and commercial payer systems across the state. We follow each payer’s claim submission format, attachment requirements, and correction procedures to eliminate technical and compliance errors.

Policy Tracking and Immediate Workflow Updates

We monitor every DHS Medical Assistance bulletin, MCO policy revision, and CMS code update. Changes are applied immediately to active claims, billing templates, and authorization records, keeping billing workflows aligned with current rules without staff intervention.

Verified Authorizations and Documentation Review

All authorizations are tracked and verified before claim submission. Documentation, CPT, and ICD-10 coding are reviewed to confirm medical necessity and payer compliance—preventing rejections for incomplete or invalid pre-approvals.

Correct Payer Sequencing and COB Management

We verify eligibility data and apply the correct payer order for dual-eligible patients. This process prevents COB mismatches, duplicate claims, and suspended reimbursements for Medicare and Medicaid crossover cases.

Structured Denial Recovery and A/R Oversight

Accounts are reviewed in 30-, 60-, and 90-day cycles. Every denial is categorized, corrected, and resubmitted with supporting evidence. Regular follow-ups with MCOs and commercial payers reduce aging A/R and recover underpaid or rejected claims.

Technical Accuracy in Submissions and Reporting

All claims, attachments, and remittance files are validated before transmission through PROMISe™ and clearinghouses. Provider identifiers, claim fields, and file structures are cross-checked against payer specifications to avoid technical rejections.

Transparent Communication and Measurable Performance

Pennsylvania providers receive performance dashboards showing claim approval rates, denial patterns, and A/R aging data. Regular updates and open reporting help practices monitor results and stay confident in their financial operations.

Meet Our Expert Pennsylvania Medical Billing Team

Our Pennsylvania medical billing team consists of certified professionals with in-depth experience across the state’s Medicaid (Medical Assistance) system, Managed Care Organizations (MCOs), and commercial insurance networks. Each team member works directly with providers to manage claims, reduce denials, and maintain consistent financial accuracy across Pennsylvania’s diverse healthcare landscape.

Expert Skill	What We Do
Certified Professionals	Our billers and coders hold AAPC and AHIMA credentials with direct experience working within Pennsylvania Medicaid (PROMISe™), UPMC Health Plan, Highmark Blue Shield, Independence Blue Cross, Geisinger Health Plan, and Aetna Better Health. They follow Department of Human Services (DHS) and MCO billing manuals to keep all claims compliant with state and federal requirements.
Payment & Reimbursement Analysis	We review Explanation of Benefits (EOBs), remittance data, and payer contracts to identify underpayments, incorrect adjustments, and missed reimbursements. These audits help Pennsylvania providers recover lost revenue and maintain stable cash flow.
Data-Driven Auditing	Each claim is checked before submission for CPT and ICD-10 accuracy, modifier use, and documentation completeness. This process improves first-pass acceptance rates, reduces denials, and strengthens overall reimbursement performance.
Denial Management & Appeals	Our billing analysts handle denials and appeals across Pennsylvania Medicaid, MCOs, and commercial payers. They identify recurring denial trends, correct root causes, and file appeals with complete documentation and payer references to recover pending revenue efficiently.

Reasons to Consider Outsourcing a Medical Billing Company in Pennsylvania

For medical practices across Pennsylvania, outsourcing medical billing provides a practical and financially efficient alternative to managing an in-house billing department. It helps providers reduce administrative workload, stay compliant with Pennsylvania Medicaid (Medical Assistance) and MCO billing requirements, and maintain consistent revenue while focusing on patient care.

Key Reasons to Consider Outsourcing Your Billing

Cost Savings

Outsourcing removes the overhead costs tied to an internal billing team—such as staff salaries, training, billing software, and clearinghouse subscriptions. According to the Healthcare Financial Management Association (HFMA), healthcare organizations can reduce administrative expenses by 30–40% by partnering with a professional billing company.

Improved Cash Flow

An outsourced billing team monitors claim progress daily, manages denials, and posts payments within 24–48 hours of remittance. This consistent workflow shortens payment cycles and helps Pennsylvania providers maintain steady cash flow without internal backlogs.

Access to Specialized Expertise

You gain direct access to certified billers and coders experienced in Pennsylvania Medicaid (PROMISe™), Medicare, and commercial payer systems such as Highmark Blue Shield, UPMC Health Plan, Independence Blue Cross, Geisinger Health Plan, and Aetna Better Health. Their working knowledge of payer policies reduces rejections and supports accurate, timely reimbursements.

Reduced Administrative Burden

Outsourcing allows front-office and clinical teams to focus on documentation, scheduling, and patient interaction instead of handling claim submissions, payment follow-ups, or appeals. This shift improves staff efficiency and reduces burnout in smaller and mid-sized practices.

Lower Denial Rates

Our billing specialists conduct detailed pre-submission audits and apply payer-specific edits before claim submission. Most clients experience a 10–15% reduction in denials within the first few billing cycles, directly improving reimbursement rates and cash flow stability.

Regulatory and Compliance Accuracy

All billing activities are aligned with HIPAA, CMS, and DHS compliance standards. Every claim is validated against the latest Pennsylvania Medical Assistance bulletins, MCO updates, and coding revisions to avoid audit exposure and post-payment corrections.

Scalability

Outsourced billing operations can expand to match your growth, whether your practice adds new specialties, providers, or service locations. You gain flexible billing capacity without the cost or delay of hiring and training additional staff.

Performance Reporting and Data Transparency

MZ Medical Billing Services provides monthly revenue reports and analytics, including denial trends, payer performance, and A/R summaries. Pennsylvania providers receive full visibility into financial operations, allowing better decision-making and strategic planning.

Stronger Focus on Patient Care

By shifting billing responsibilities to experienced professionals, providers can dedicate more time to clinical outcomes and patient engagement. MZ Medical Billing maintains accurate, compliant billing operations that support steady collections across all major Pennsylvania payers.

Pennsylvania Medical Billing & RCM Services – Supporting Providers Across All 50 States

MZ Medical Billing Services provides full-service Medical Billing and Revenue Cycle Management (RCM) services for healthcare providers in Pennsylvania and nationwide. Our certified billing professionals manage every stage of the billing process, from charge entry and claim submission to denial management, accounts receivable recovery, and financial reporting, keeping reimbursements accurate, compliant, and on schedule.

We work with practices across Philadelphia, Pittsburgh, Allentown, Erie, and Harrisburg, as well as hospitals, specialty groups, and outpatient centers throughout the country.

Each claim is reviewed for alignment with Pennsylvania Medicaid (Medical Assistance) rules, PROMISe™ portal requirements, and payer-specific documentation standards before submission. This process reduces denials and maintains predictable revenue flow.

Our billing specialists stay current with state Medicaid programs, MCO rules, and federal payer regulations across all 50 states. From Pennsylvania’s DHS Medical Assistance policies to Florida’s Agency for Health Care Administration (AHCA) Medicaid and the Ohio Department of Medicaid (ODM), we apply the correct billing, coding, and documentation standards for every payer system.

With MZ Medical Billing, healthcare providers gain a partner with Pennsylvania-based Medicaid and MCO expertise backed by nationwide RCM experience, helping practices maintain consistent financial accuracy, regulatory compliance, and long-term billing efficiency in every state.

United States - States Map - Our Medical Billing Locations

Medical Billing Services for All Healthcare Specialties in Pennsylvania

MZ Medical Billing oversees the entire revenue cycle for healthcare providers across Pennsylvania, supporting nearly every medical specialty practiced in the state and nationwide. Our certified billers and coders manage claims for hospitals, physician groups, outpatient centers, and specialty clinics with precision. Each claim is processed using accurate coding, verified documentation, and payer-specific billing rules in line with the Pennsylvania Department of Human Services (DHS), Medical Assistance (Medicaid), and all major commercial insurers operating across the state.

We manage billing for:

Primary and Specialty Care – Family medicine, internal medicine, pediatrics, geriatrics, and multi-specialty clinics serving urban and rural Pennsylvania communities.
Behavioral and Mental Health – Psychiatry, psychology, substance use treatment, counseling, and community-based mental health programs billed in accordance with Pennsylvania Medicaid and MCO requirements.
Therapy and Rehabilitation – Physical, occupational, and speech therapy billing with accurate modifiers, documentation review, and compliance with DHS and CMS standards.
Surgical and Hospital-Based Practices – General surgery, anesthesia, cardiology, orthopedics, gastroenterology, urology, ENT, and other high-volume procedural specialties requiring precise charge capture and modifier management.
Chiropractic and Pain Management – Coding and billing support for chiropractic therapy, interventional pain procedures, and physical medicine services under Pennsylvania Medicaid and private payer policies.
Behavioral and Substance Use Treatment Centers – Residential and outpatient programs, MAT (Medication-Assisted Treatment) billing, and multi-payer documentation management.
Urgent Care and Walk-In Clinics – E/M code validation, same-day billing, and accurate claim handling for high-turnover patient visits across Pennsylvania’s urgent care networks.
Imaging and Diagnostic Services – Radiology, pathology, and laboratory billing with compliance checks for technical and professional components under DHS and Medicare billing rules.
Dental and Ancillary Services – Dental-to-medical crossover claims, DME suppliers, and ambulatory surgical centers requiring payer-specific billing alignment.
Specialized Outpatient and Facility Billing – Rehabilitation hospitals, community health centers, and Federally Qualified Health Centers (FQHCs) operating under PROMISe™ and MCO systems.

By outsourcing medical billing to MZ Medical Billing, Pennsylvania healthcare providers gain a team experienced in handling claims across every major specialty, following state Medicaid, Medicare, and commercial payer standards with full compliance and operational precision. This approach helps practices strengthen revenue, minimize denials, and maintain stable cash flow across all service lines.

Applied Behavior Analysis

Behavioural Health

Pediatric

Mental Health

Physical Therapy

Occupational Therapy

Speech Therapy

Anesthesiology

Why Choose MZ Medical Billing in Pennsylvania

Partnering with MZ Medical Billing gives Pennsylvania healthcare providers access to certified billing specialists who understand Pennsylvania Medicaid (Medical Assistance) policies, Managed Care Organization (MCO) rules, and Medicare Part B requirements. Our billing team applies precise coding, documentation review, and revenue cycle analysis to help providers across Pennsylvania and nationwide maintain consistent collections and compliance.

Local and Nationwide Support

We actively support medical practices throughout Philadelphia, Pittsburgh, Allentown, Harrisburg, Erie, and Scranton, with dedicated account managers available in real time. Our nationwide operations across all 50 states allow us to identify and apply state-specific payer variations, including PROMISe™ portal requirements and DHS Medical Assistance updates.

Data-Driven Billing Strategy

Each provider account is managed using verified claims data, payer trend analysis, and denial statistics. This allows us to detect the root causes of delayed payments and correct workflow inefficiencies directly within your billing or EHR system.

Certified and Compliant Billing

All billing is performed by AAPC- and AHIMA-certified coders following HIPAA, CMS, and OIG guidelines. We continuously track DHS Medical Assistance updates, MCO policy bulletins, and CMS code revisions to maintain claim accuracy and full regulatory compliance.

Higher Collection Performance

Our clients typically reach a 97–98% first-pass claim acceptance rate and maintain accounts receivable under 30 days. These results are supported by ongoing denial tracking, documentation review, and active payer follow-up.

Established Payer Network

We manage claims for over 100 regional and national payers, including Highmark Blue Shield, Independence Blue Cross, UPMC Health Plan, Geisinger Health Plan, Aetna Better Health, and Medicare/Medicaid dual coverage cases. Each payer’s submission format, authorization rules, and reimbursement structure are applied accurately to prevent denials.

Transparent Financial Reporting

Pennsylvania providers receive detailed financial reports that include claim turnaround times, denial categories, payer reimbursement performance, and monthly revenue recovery summaries. These reports support internal audits and financial planning with full transparency.

Patient-Focused Billing Communication

We handle billing inquiries, statement processing, and payment coordination with professionalism and clarity. This reduces administrative strain for your staff and provides patients with accurate, easy-to-understand billing communication.

Long-Term Practice Growth

MZ Medical Billing works as an extension of your business office — not a temporary outsourcing vendor. We strengthen your revenue performance through accuracy, continuous compliance monitoring, and alignment with Pennsylvania DHS and payer policy changes.

Get a FREE Consultation With a Pennsylvania Billing Specialist!

What are you waiting for? Schedule an appointment with our Pennsylvania medical billing specialists and discover how we can help your practice achieve higher reimbursement and cleaner claims. We apply structured billing processes, compliance-driven quality control, and payer negotiation strategies that help reduce denials and improve cash flow.

Contact MZ Medical Billing for a personalized consultation today. Our team is more than just a billing vendor — we act as your financial operations partner. We’ll help you strengthen your revenue cycle, accelerate payments, and maintain compliance with Pennsylvania Medicaid (Medical Assistance) and commercial payer rules.

Get in touch today to learn how MZ Medical Billing can help your Pennsylvania practice reach its financial goals with accuracy, efficiency, and complete transparency.

FAQS

Pennsylvania Medical Billing FAQs

How can I enroll as a provider with Pennsylvania Medicaid (Medical Assistance)?

Provider enrollment is managed through the Pennsylvania Department of Human Services (DHS) PROMISe™ system. You’ll need to complete an online enrollment application, provide credentialing documentation, and select appropriate service locations and taxonomy codes. Our team can assist in reviewing your PROMISe™ account setup to confirm your enrollment is active and linked correctly to your NPI and service locations.

What is the filing deadline for Pennsylvania Medicaid claims?

Under Pennsylvania Medical Assistance, claims must generally be filed within 180 days from the date of service. Managed Care Organizations (MCOs) may have shorter deadlines (often 90 or 120 days). If a claim is denied and needs correction, resubmission must occur within the same time frame.

How do I submit and track prior authorizations for Pennsylvania Medicaid and MCOs?

Authorizations can be submitted through the PROMISe™ portal or through your MCO’s designated authorization portal (e.g., UPMC Health Plan, Aetna Better Health, or Highmark Wholecare). It’s essential to attach medical necessity documentation and confirm approval before the date of service. We track all authorization requests from submission to approval to prevent claim delays.

What should I do if a claim is denied by Pennsylvania Medicaid or a commercial payer?

Review the remittance advice (RA) or EOB for the denial reason code, then determine whether the issue involves missing data, incorrect coding, or authorization. Our billing team categorizes denials, corrects the source issue, and resubmits through the PROMISe™ system or the payer’s EDI channel with all required attachments.

How often does Pennsylvania Medicaid update its fee schedules or provider bulletins?

The DHS updates fee schedules and provider handbooks several times per year, often following CMS or CPT code revisions. MCOs such as UPMC for You, AmeriHealth Caritas, and Geisinger Health Plan also issue quarterly updates. We monitor all bulletins and apply changes immediately to prevent reimbursement discrepancies.

What happens if a patient has both Medicare and Pennsylvania Medicaid coverage?

In dual-eligibility cases, Medicare is billed first, and the crossover claim is sent automatically (or manually if needed) to Pennsylvania Medicaid for secondary payment. Filing sequence errors are a common cause of delayed payment. Our billing system validates COB sequencing before each submission.

How can I reduce aged or unpaid accounts receivable (A/R) beyond 60 or 90 days?

Regular denial categorization and structured follow-up are key. We recommend tracking A/R by payer and aging category, addressing top denial reasons (coding errors, invalid authorizations, etc.), and maintaining weekly follow-up cycles. Our A/R specialists recover outstanding balances by coordinating directly with MCOs and commercial payers.

Do small or solo practices in Pennsylvania benefit from outsourcing medical billing?

Yes, outsourcing eliminates overhead tied to billing staff, software, and training. Many small practices reduce administrative costs by up to 30–40% while improving payment turnaround. It also ensures compliance with complex Medicaid and MCO rules without internal staff having to manage policy updates.

How can I verify patient insurance eligibility before service?

Eligibility for Medicaid can be checked through the PROMISe™ portal or through payer-specific clearinghouses for MCOs and commercial plans. We verify eligibility and coverage details 24–48 hours before appointments to avoid claim holds or patient balance disputes.

What are common audit or compliance risks for Pennsylvania providers?

The DHS and MCOs routinely audit claims for coding accuracy, medical necessity, and duplicate billing. Providers who bill for services outside of their scope, use outdated codes, or lack documentation risk recoupments or suspended payments. We perform internal compliance reviews to minimize audit exposure.

How do healthcare providers stay compliant with Pennsylvania Medicaid billing requirements?

By monitoring DHS Medical Assistance updates, MCO bulletins, and CMS policy revisions. Our compliance specialists apply these changes across your active claims and billing workflows so your practice stays aligned with current reimbursement and audit standards.

What does a complete revenue cycle management (RCM) process look like in Pennsylvania?

RCM includes eligibility verification, charge capture, coding review, claim submission through PROMISe™ or clearinghouses, payment posting, denial correction, and A/R reporting. Each phase is tracked and measured to improve reimbursement speed and accuracy.

Can Pennsylvania providers bill for telehealth services through Medicaid or MCOs?

Yes. Most Pennsylvania MCOs and Medical Assistance programs reimburse telehealth services when billed with appropriate POS codes and telehealth modifiers (e.g., 95 or GT). Coverage rules differ slightly between MCOs, and our billing team keeps track of current telehealth guidelines for each payer.

How does Electronic Visit Verification (EVV) apply to Pennsylvania providers?

EVV is required for all home health and personal care services under Act 150 and the Medicaid Home Health program. Providers must record visit start and end times electronically using the DHS-approved system. Claims missing EVV data may be denied or suspended.

How does MZ Medical Billing help resolve claim denials and payment delays in Pennsylvania?

We track all denials through detailed root-cause analysis, correct data or documentation issues, and resubmit claims with supporting records. Most practices see denial rates drop by 10–15% and A/R days shorten significantly after partnering with our Pennsylvania billing team.

We Serve All 50 States