Verified October 10, 2026 against the statutes, regulations and sources cited below. General information, not legal advice. All states
What providers miss in Pennsylvania
- In HealthChoices, the network contract is made effective back to the date the MCO received a complete credentialing application.
- Plans may not exclude a provider for advocating for medically necessary care, filing a grievance, or treating many patients with expensive conditions.
Does Pennsylvania have an any willing provider law?
No any willing provider law for medical providers was confirmed.
How long can a plan take to credential a provider in Pennsylvania?
HealthChoices MCOs must acknowledge an application within 10 days, send a status letter within 30 days, and approve or deny within 60 days of a complete packet. A denial must list every requirement not met.
- Deadline: 60 days
- Applies to: Medicaid physical health MCOs (HealthChoices), by state contract; no commercial deadline found
Citation: Pennsylvania HealthChoices agreement
What network adequacy rules apply in Pennsylvania?
Managed care plans must give at least 90 percent of enrollees in each county access to covered services within 20 miles or 30 minutes in metropolitan counties, and 45 miles or 60 minutes elsewhere.
Citation: 28 Pa. Code 9.679(d)
Clear rationale for denials
A managed care plan's credentialing system must notify providers of denials and nonrenewals with a clear rationale for the decision, and the plan must disclose its credentialing criteria on written request.
Citation: 28 Pa. Code 9.761
Will the Pennsylvania insurance department take a provider complaint?
- Pennsylvania Insurance Department
Who oversees Medicaid managed care plans in Pennsylvania?
- Pennsylvania Department of Human Services (HealthChoices)
Turned down by a plan in Pennsylvania?
We read the denial, check which of these rules reach that plan, and prepare the reconsideration request, the access-gap evidence and any regulator complaint the law supports; you sign and send them, and we track every deadline. Self-funded employer plans follow federal law, not Pennsylvania's. A rejection review is $249, credited toward a dispute.