Pennsylvania Credentialing and Network Rules

Pennsylvania's credentialing law does not set a commercial credentialing deadline. What it does have is a set of transparency and fairness duties that are useful in a dispute: a written, clear rationale for any credentialing denial, disclosure of the criteria, protected reasons for which a provider may not be excluded, and travel standards for managed care networks. Its Medicaid managed care contract adds firm timelines.

What does 40 P.S. 991.2121 require?

Section 2121 of Act 284 of 1921 (40 P.S. 991.2121), as amended November 3, 2022 (Act 146), applies to "An insurer or MA or CHIP managed care plan," meaning Medical Assistance and children's health insurance plans as well as insurers. It requires:

• "a credentialing process to enroll qualified health care providers and create an adequate provider network" (2121(a)), with written criteria for initial credentialing, renewal, and restricting or terminating credentials, subject to the department's approval (2121(a.1));
• a report on the credentialing process "at least every two (2) years" (2121(c));
• disclosure of "relevant credentialing criteria and procedures to health care providers that apply to participate or that are participating" (2121(d)); and
• when it "denies enrollment or renewal of credentials to a health care provider," written notice that "shall include a clear rationale for the decision" (2121(f)).

It also bars excluding or terminating a provider because the provider engaged in the activities listed in section 2113(c), has "a practice that includes a substantial number of patients with expensive medical conditions," or objects to or refuses a service on moral or religious grounds (2121(e)).

What does the Department of Health's rule add?

For managed care plans, 28 Pa. Code 9.761 fills in the details. The plan's credentialing system must cover, among other things, recredentialing "at least every 3 years," an assessment of providers' "ability to enroll additional patients in the practice," and "In cases of denial or nonrenewals, notification to health care providers that includes a clear rationale for the decision" (9.761(a)). The plan submits its credentialing plan to the department for approval (9.761(b)), and "Upon written request, a plan shall disclose relevant credentialing criteria and procedures to health care providers that apply to become participating providers" (9.761(e)).

The biennial report is worth knowing about. It must include "The number of applications made to the plan," "The number of applications approved," "The number of applications rejected" and "The number of providers terminated for reasons of quality" (9.761(f)). A plan that says it is closed is also reporting how many applications it rejects.

Which travel standards apply to Pennsylvania managed care networks?

Under 28 Pa. Code 9.679(d), a plan must give "at least 90% of its enrollees in each county in its service area, access to covered services that are within 20 miles or 30 minutes travel from an enrollee's residence or work in a county designated as a metropolitan statistical area (MSA) by the Federal Census Bureau, and within 45 miles or 60 minutes travel from an enrollee's residence or work in any other county." The listed services that must meet those standards include primary care, OB/GYN, psychiatry and neurology, orthopedic surgery, physical medicine and rehabilitation, urology and others (9.679(e)).

When a plan cannot meet the standards, "it shall inform the Department in writing and provide a written description of why it is unable to do so and its alternative arrangements," including whether it will use nonparticipating providers and the payment arrangements (9.679(f)). And members are protected: "A plan shall cover services provided by a nonparticipating health care provider at no less than the in-network level of benefit when the plan has no available network provider" (9.679(k)). Plans must also describe their network to the department annually and on request "to enable the Department to analyze network disruptions or investigate complaints" (9.679(m)).

For a provider, 9.679(f) and (k) together suggest the questions to ask: does the plan meet the travel standard in your county for your service, and if not, what alternative arrangement did it file? Our post on time and distance standards explains how to test that.

How does Pennsylvania Medicaid handle credentialing?

UnitedHealthcare's State and Federal Regulatory Addendum (revised 9/2026) restates the HealthChoices physical health contract terms that plans must follow:

• An acknowledgment of the application within 10 calendar days, a status letter within 30 calendar days saying the application is clean or listing what is missing, and an approval or denial "within a maximum of sixty (60) calendar days." A denial "should include all of the requirements that were not met."
• Credentialing cannot be completed until the provider has a Medicaid ID (PROMISe) number from the Department of Human Services, though a plan may not delay processing for the lack of one.
• "The PH-MCO shall make the network contract effective date from credentialing application approval retrospective to the date a complete credentialing application was received."
• Plans must use a centralized credentialing vendor when the department selects one, with the plan making the final decision.

Where do Pennsylvania's rules stop?

• They do not require a plan to accept every provider. They require reasons, disclosure, fair treatment and adequate networks.
• Self-funded employer plans are generally outside state insurance law under ERISA.
• Medicare Advantage follows federal rules; state laws on provider inclusion are superseded there.

After a denial, which steps come first?

1. Ask in writing for the "clear rationale" if the denial lacks one, citing 40 P.S. 991.2121(f) and 28 Pa. Code 9.761(a)(7).
2. Ask for the plan's credentialing criteria and procedures under 9.761(e).
3. If the reason is network size, gather travel times and wait times for your county and service, and ask how the plan meets 9.679(d).
4. For HealthChoices, confirm your PROMISe ID and the date your complete application was received.
5. Request reconsideration through the plan's process before going to a regulator.

Where we fit

We research, prepare and organize; we are not a law firm. A Network Rejection Review ($249, credited toward a dispute) reads the denial against 991.2121 and Chapter 9 and maps your deadlines. A Payer Network Dispute ($799 per payer, $1,999 for three) prepares the rationale and criteria requests, the access evidence and the reconsideration letter for you to sign and send, and we track every reply. A contract or credentialing approval carries a flat $1,500 win fee. Legal questions go to a Pennsylvania healthcare attorney. See our Pennsylvania page and Medicaid uniform credentialing.