MedStats Billing delivers end-to-end revenue cycle management built for Pennsylvania practices. We audit for the 10% interest Act 68 attaches to clean claims left unpaid past 45 days, price auto injury care against the 110% Act 6 ceiling and work injury care against the 113% Medicare cap, and bill every HealthChoices physical health plan across all five zones alongside the county behavioral health carve-out.
Pennsylvania runs three separate payment regimes over the same patient population, each with its own ceiling and its own clock. Commercial and Medical Assistance managed care claims sit under Act 68 at 45 days with automatic 10% interest. Auto injury care is capped at 110% of the Medicare prevailing charge and payable in 30 days. Work injury care is capped at 113% of Medicare with a fee review window that closes in 90 days. Add a behavioural health carve-out that rejects claims sent to the wrong plan and five HealthChoices zones with different plan lineups, and a practice that treats all of it as one workflow underbills most of it.
Pennsylvania Billing Specializations:
Built to bring clarity, control and consistency to your Pennsylvania practice’s revenue cycle.
MedStats Billing manages the complete revenue cycle for Pennsylvania providers — from PROMISe enrollment and PH-MCO, CHC and county BH-MCO credentialing, through coding, claim scrubbing and submission, to denial resolution, Act 68 interest recovery and fee review applications before the Bureau of Workers’ Compensation.
Certified CPT, ICD-10-CM, and HCPCS coding with pre-submission claim scrubbing built around each payer's edits, so claims pay on the first pass. We manage charge entry, claim submission, payment posting, and insurance follow-up.
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Enrollment with Medicaid managed care plans, Medicare via PECOS, and commercial payers — plus CAQH maintenance and re-credentialing deadline tracking, so your providers stay in-network and billable without gaps.
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Coverage confirmed before the visit — active policy status, deductibles, co-pays, plan type, and prior authorization requirements — so front-end denials are caught while there is still time to fix them.
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Aged claims worked by payer and denial reason, with appeals filed inside each plan's window. We monitor outstanding balances, manage rejections, and drive down days in A/R to protect cash flow.
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A detailed review of coding accuracy, documentation standards, and denial patterns that identifies revenue leakage and compliance exposure — before a payer audit finds it for you.
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Explore servicePennsylvania practices lose more revenue to the wrong ceiling and the missed window than to coding, and three of the four leaks below are statutory money the payer already owes. These are the four we eliminate:
Act 68 requires 10% per annum interest on a clean claim not paid within 45 days, added to the payment without the provider filing anything and paid within 30 days of the claim. Because it is automatic, nobody reconciles whether it actually arrived — and usually it has not.
Under 31 Pa. Code § 154.18 the uncontested portion of a contested claim must be paid inside the same 45 days as a clean claim. Practices routinely let an entire claim sit while one line item is disputed, and the interest on the uncontested balance is never pursued.
Pennsylvania carves behavioral health out of HealthChoices to county-designated BH-MCOs. Behavioral claims billed to a physical health plan such as Keystone First or UPMC for You reject outright, and payment requires a separate contract with the county BH-MCO.
A work injury bill needs the HCFA 1500 or UB-04 plus a completed LIBC-9, and the payer then has 30 days to process it. An Application for Fee Review must be filed in WCAIS within 90 days of the original billing date or 30 days of dispute notification, whichever is later. Miss it and the underpayment is permanent.
Licensed insurers and managed care plans must pay clean claims, and the uncontested portions of contested claims, within 45 days of receipt. Interest of 10% per annum runs from the day after the due date to the date of payment, is added to the amount owed without a separate claim, and must be paid within 30 days of the claim payment. MA and CHIP managed care plans carry the same 45-day duty.
Treatment of an auto injury is capped at 110% of the applicable Medicare prevailing charge, benefits are overdue if not paid within 30 days and then carry 12% per annum, reasonableness and necessity are challenged through a peer review organisation, and the provider may not balance bill the patient for the difference.
Medical fees for work injury care are capped at 113% of the applicable Medicare reimbursement rate, then updated annually by the percentage change in the statewide average weekly wage. Payers have 30 days to process a properly submitted bill, balance billing the injured worker is prohibited, and fee disputes go to the Bureau with a further appeal to a hearing officer within 30 days.
Seven physical health plans serve HealthChoices across five zones: AmeriHealth Caritas (Southwest, Northwest, Lehigh/Capital, Northeast), Geisinger Health Plan Family, Health Partners Plans and UPMC for You statewide, Highmark Wholecare (Lehigh/Capital, Southwest), Keystone First and UnitedHealthcare Community Plan (Southeast). Community HealthChoices covers duals and LTSS through AmeriHealth Caritas, PA Health & Wellness and UPMC Community HealthChoices, and behavioral health is billed to the county BH-MCO.
MedStats Billing provides tailored billing solutions for a wide range of medical specialties, ensuring accurate coding, fewer denials, and faster reimbursementsto maximizes your revenue potential.
MedStats Billing handles PROMISe enrollment, PH-MCO, CHC and BH-MCO credentialing, three-regime claim pricing, Act 68 interest recovery and fee review applications across Pennsylvania, giving practices end-to-end RCM support in a state where the ceiling changes with the payer.
Claims are scrubbed against HealthChoices plan and commercial payer edits before submission to drive clean first-pass reimbursement.
Every claim is priced against the right ceiling — the commercial or HealthChoices contract, 110% of Medicare for auto injury, or 113% for work injury — before it leaves the practice.
We reconcile the 45-day clock on every clean claim and pursue the 10% Act 68 interest, and the 12% on overdue auto benefits, rather than assuming the payer added it.
Working knowledge of Highmark, Independence Blue Cross, UPMC Health Plan, Capital Blue Cross, Geisinger, Aetna, the seven HealthChoices physical health plans and the county BH-MCOs.
Whether you practise in Philadelphia, Pittsburgh, Allentown, Harrisburg or Erie, our workflows adjust seamlessly as your group grows across the five HealthChoices zones.
HIPAA-compliant data handling and controlled access protect patient health information and billing records at every stage.
We integrate smoothly with widely used EHR platforms to ensure accurate data flow from documentation to claim submission. This reduces manual errors, speeds processing, and supports cleaner reimbursements.
We work alongside leading systems including:
Schedule a complimentary billing assessment with MedStats Billing to uncover hidden revenue loss, confirm your auto and work injury claims were priced against the correct statutory ceiling, and quantify the Act 68 interest your practice is owed on late-paid clean claims.
Under Act 68, at 40 P.S. § 991.2166, a licensed insurer or managed care plan must pay a clean claim within 45 days of receipt, and the same deadline applies to the uncontested portion of a contested claim. Interest of 10% per annum is added to the amount owed, calculated from the day after the payment was due until the claim is paid, and must be paid within 30 days of the claim payment. Interest of less than $2 on a single claim need not be paid.
No. 31 Pa. Code § 154.18 applies the prompt payment rule to health insurance policies and expressly excludes automobile and workers’ compensation policies. Those claims run on their own clocks: auto benefits are overdue 30 days after the insurer receives reasonable proof and then carry 12% per annum, and a work injury payer has 30 days to process a properly submitted bill.
Under 75 Pa.C.S. § 1797, reimbursement for treatment of an auto injury is capped at 110% of the applicable Medicare prevailing charge or the provider’s usual and customary charge, whichever is less. The provider may not balance bill the patient for the difference, and an insurer challenging the reasonableness or necessity of treatment must route it through a peer review organisation rather than simply denying it.
Medical fees for services rendered under the Workers’ Compensation Act are generally capped at 113% of the applicable Medicare reimbursement rate under 77 P.S. § 531 and 34 Pa. Code § 127.101. Rates were frozen and are updated annually by the percentage change in the statewide average weekly wage, and the Bureau publishes Part B fee schedules by geographic region. Balance billing the injured worker is prohibited.
A fee review must be filed in WCAIS within 90 days of the original billing date or 30 days after notification of a disputed treatment, whichever is later, and not before 33 days have passed since the bill was properly sent. The application must include the completed LIBC-9 medical report and copies of the original bills. An adverse administrative decision can be appealed to a hearing officer within 30 days.
Seven physical health plans operate across the five zones: AmeriHealth Caritas in the Southwest, Northwest, Lehigh/Capital and Northeast; Geisinger Health Plan Family, Health Partners Plans and UPMC for You statewide; Highmark Wholecare in Lehigh/Capital and the Southwest; and Keystone First and UnitedHealthcare Community Plan in the Southeast. Community HealthChoices serves dual eligibles and LTSS participants through AmeriHealth Caritas, PA Health & Wellness and UPMC Community HealthChoices, while behavioral health is billed to the county-designated BH-MCO.
We serve practices and healthcare facilities statewide across all five HealthChoices zones, including Philadelphia, Pittsburgh, Allentown, Reading, Erie, Scranton, Bethlehem, Lancaster, Harrisburg, York, Altoona, Wilkes-Barre, State College and Chester.
