[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-301641-105":53,"doc-detail-301641-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","odp-promise-provider-enrollment-readiness-packet-version-50","ODP PROMISe Provider Enrollment Readiness Packet - Version 5.0","","ODP PROMISeTM Provider Enrollment Readiness Packet guides MR providers through the PROMISeTM Provider Enrollment process. It links to base application instructions, provider type and specialty code references, and examples for acceptable versus unacceptable IRS documentation for verifying IRS numbers. It includes a packet checklist and detailed provider enrollment base application field completion instructions, covering typed/ink requirements, effective date considerations, service-location rules, and when NPI, taxonomy codes, SSN, and FEIN documentation are required.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/odp-promise-provider-enrollment-readiness-packet-version-50/301641/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/odp-promise-provider-enrollment-readiness-packet-version-50/301641.png","ImageObject",442,249,{"name":88,"@type":89},"Levi","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-25","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the purpose of the ODP PROMISeTM Provider Enrollment Readiness Packet?","Question",{"text":108,"@type":109},"It helps guide MR providers through the PROMISeTM Provider Enrollment process, including where to find application instructions and how to complete required information.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How should the Provider Enrollment Base Application be completed and submitted?",{"text":113,"@type":109},"Applications must be typed or completed by hand using black ink, all required spaces must be completed with correct information or N/A, and it must be printed and submitted as a single-sided document.",{"name":115,"@type":106,"acceptedAnswer":116},"When is NPI and taxonomy documentation required?",{"text":117,"@type":109},"For healthcare provider types 05, 16, 17, 19, 21, or 52 (with specified specialties), the packet requires a legible copy of the NPPES Confirmation letter showing the NPI and taxonomy assignments, plus entering the NPI number and taxonomy codes.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},301641,1790051274,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":35,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":140},7971461740909,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","ODP PROMISeTM Provider Enrollment Readiness Packet  \nThis packet contains information that will help guide MR providers through the PROMISeTM Provider Enrollment Process.  \nUse the following links to go directly to the document you would like to view:  \nPROMISeTM Provider Enrollment Base Application Instructions  \nODP Provider Types and Specialty Codes  \nExamples of Acceptable Documentation to Verify IRS Numbers  \nExamples of Unacceptable Documentation to Verify IRS Numbers  \nPROMISeTM Provider Enrollment Packet Checklist  \nVersion 5.0  \n-1-  \nPROMISeTM Provider Enrollment Base Application Instructions  \nPrint the Provider Enrollment Base Application from the DPW web site at: [http://www.dpw.state.pa.us](http://www.dpw.state.pa.us. To)[. To](http://www.dpw.state.pa.us. To)[ ](http://www.dpw.state.pa.us. To)[download the application:](download the application:)  \n1. Click the Provider Information hyperlink (on the left side of the screen);  \n2. Click the PROMISeTM hyperlink;  \n3. Click the Provider Enrollment Information hyperlink;  \n4. Navigate to your appropriate provider type;  \n5. Click the Enrollment Application and Requirements hyperlink.  \nIMPORTANT NOTES:  \n• Applications must be typed or completed by hand using black ink.  \n• Complete ALL SPACES as required on the application with either your correct information, or N/A.  \n• The application must be printed and submitted as a single-sided document.  \n• Out-of-state providers must submit proof of participation in that state’s Medicaid program.  \nSpecific Field Completion Instructions  \n\n| Field | Description and Completion Notes |\n| --- | --- |\n| 1. | Enter the complete name of the individual or the facility.\u003Cbr>NOTE: The facility name cannot include a street address. |\n| 2a. | Select Initial Enrollment. Select Individual or Facility. Write the MPI and service location on the right side of this line.\u003Cbr>NOTE: For each unique service location, a new application must be completed. |\n| 2b. | If you are re-activating a closed service location that was enrolled in PROMISeTM in the past, check this box and enter your nine (9) digit MPI number and four (4) digit service location code. |\n| 2c. | If this is a name change, indicate both the old name and the new name.\u003Cbr>NOTE: To verify your new name, a copy of your Social Security card or IRS FEIN documentation must accompany your application. |\n| 2d. | Do not complete this section. |\n| 3. | IMPORTANT: This cell must be completed for all healthcare provider types 05, 16, 17, 19, 21, or 52 (with specialties 456 or 520) . Include a legible copy of the NPPES Confirmation letter that shows the NPI Number and Taxonomy(s) assigned to the health care provider applying for enrollment.\u003Cbr>Enter your ten (10) digit NPI number, and ten (10) digit taxonomy code(s) . If you have more than four (4) taxonomy codes, please attach an additional sheet noting the additional codes.\u003Cbr>\u003Cbr>NOTE FOR PROVIDER TYPE 26, 51, 52 (for specialties, 521, 522, and 524), 53, 54 and 55: These provider types are considered an atypical (non-healthcare) provider type; therefore, no NPI is needed.\u003Cbr>NOTE FOR PROVIDER TYPE 21: This provider type needs to coordinate changes with the ODP Case Management lead when providing this service for the Office of Developmental Programs. There are changes that must take place in HCSIS for claims to process correctly. |\n| 4. | Enter the requested effective date for your action request. Check with your County on what |\n\nVersion 5.0 -2-  \n\n| Field | Description and Completion Notes |\n| --- | --- |\n|  | date should appear here.\u003Cbr>NOTE: If claims are submitted in PROMISe™ using a date prior to the Requested Effective Date, they will be denied. |\n| 5. | Enter your provider type number and description. Refer to the Provider Type/Specialty Codes list, available within this document, for assistance. |\n| 6. | Enter your specialty name and code number. Refer to the Provider Type/Specialty Codes list, available within this document, for ass","cbCaihZb555itq4q","https://ap.wps.com/l/cbCaihZb555itq4q","pdf",592426,"English","# PROMISeTM Provider Enrollment Readiness Packet\n## Provider Enrollment Base Application Instructions\n## Specific Field Completion Instructions\n## Version 5.0","[{\"question\":\"What is the purpose of the ODP PROMISeTM Provider Enrollment Readiness Packet?\",\"answer\":\"It helps guide MR providers through the PROMISeTM Provider Enrollment process, including where to find application instructions and how to complete required information.\"},{\"question\":\"How should the Provider Enrollment Base Application be completed and submitted?\",\"answer\":\"Applications must be typed or completed by hand using black ink, all required spaces must be completed with correct information or N/A, and it must be printed and submitted as a single-sided document.\"},{\"question\":\"When is NPI and taxonomy documentation required?\",\"answer\":\"For healthcare provider types 05, 16, 17, 19, 21, or 52 (with specified specialties), the packet requires a legible copy of the NPPES Confirmation letter showing the NPI and taxonomy assignments, plus entering the NPI number and taxonomy codes.\"}]","ODP PROMISe Provider Enrollment Readiness Packet - Version 5.0 | PDF",1789784257,6]