Community HealthChoices for Home Care Providers

If your agency provides Personal Assistance Services (PAS) to Medicaid participants in Pennsylvania, most of that work runs through Community HealthChoices (CHC). Payment depends on more than completing the visit: the service has to fit the service plan and the authorization, and it has to be documented and verified in EVV.

This guide explains where to check service-start dates, authorized hours, EVV records and payment issues, with links to the rules and payer guidance, and what to review every week.

Start here: check the approved service plan, confirm the start date with the MCO, compare scheduled and delivered units with the authorization, and review EVV separately before billing.

This article is general information for Pennsylvania home care agencies. It is not legal, billing or licensing advice. Your provider agreement with each MCO and the current DHS bulletins control.

What Community HealthChoices is

Community HealthChoices is Pennsylvania's Medicaid managed care program for long-term services and supports for adults. The Office of Long-Term Living (OLTL) in the Department of Human Services (DHS) oversees it, and three managed care organizations (MCOs) run it:

• Keystone First CHC (AmeriHealth Caritas)
• PA Health & Wellness (Centene)
• UPMC Community HealthChoices

According to the Pennsylvania Homecare Association (PHA), more than 155,000 Medicaid participants receive PAS in the state (PHA testimony to the Senate Democratic Policy Committee, November 10, 2025).

For an agency, each MCO is a separate payer with its own provider agreement, provider manual, and communications. In practice, all three use HHAeXchange as the provider portal for PAS: DHS states that providers serving CHC participants "will have the option to use the MCO's EVV system, HHAeXchange." That portal is where authorizations, confirmed visits, MCO messages and claims live. PA Health & Wellness puts it in writing: since October 19, 2020, PAS (W1793) and respite (T1005) "can only be billed through HHAeXchange."

The person-centered service plan sets the ceiling

Every PAS hour you can bill starts with the participant's person-centered service plan (PCSP). The MCO's service coordinator builds it after the assessment, and the 2026 CHC Agreement requires that "the finalized PCSP must include the type, scope, amount, duration and frequency of the services authorized."

State regulation ties payment to that plan. Under 55 Pa. Code § 52.42(d), "The Department will only pay for a service in the type, scope, amount, duration and frequency" of the approved plan. Under § 52.42(h), there is no payment for serving a participant "who does not have an approved service plan."

Read that as five separate limits, not one number of hours:

Plan element	What it means on the schedule
Type	The service code (for example, PAS vs. respite)
Scope	What the caregiver does during the visit
Amount	Units authorized per period
Duration	Start and end dates of the authorization
Frequency	How often visits occur (days per week, visits per day)

A schedule that fits the weekly hours but not the frequency, or that runs past the end date, can still produce visits that do not bill.

New and increased PAS must start within 7 business days

The 2026 CHC Agreement requires that new or increased PAS "commence within seven (7) business days of the approval, unless the Participant requests a longer timeframe."

Keystone First CHC sent PAS providers a start-date reminder on August 28, 2025. Among its suggestions: "Confirm on-call availability of staff for immediate response" and "Maintain contingency plans for backup assistance in case of staff unavailability."

Seven business days is a short window when you consider what PHA says agencies often receive with a referral: "Providers are routinely expected to accept referrals with only a participant's name, address, phone number, and authorized hours" (PHA response to the CHC RFI, July 14, 2026). The same document says this "contributes to delayed starts of care, failed placements, caregiver turnover, and poorer participant outcomes."

What helps in practice:

• Accept a referral only after someone has checked caregiver availability against the authorized frequency, not just the weekly hours.
• Make the first contact with the participant the same day the authorization appears.
• Have a named backup caregiver for the first two weeks of every new case.
• Keep someone reachable after hours, because new-start problems (a caregiver who cannot make the first visit, a participant who needs to reschedule) often surface in the evening.

Check authorization limits and EVV records separately

When a visit exceeds what the authorization allows, expect a hold or a denial rather than a partial payment. Authorization and EVV are two different checks, and a visit can fail either one.

• In HHAeXchange, the visit is held in Prebilling with an authorization validation error. HHAeXchange's own process guide notes that "in some cases, the Authorization validation error cannot be corrected," for example when "the number of allotted units has been exceeded."
• At the state level, the EVV codes measure something different. ESC 927, "PCS Units Billed Exceed Units Verified in EVV," means the units billed exceed the units verified in EVV, and ESC 928, "No Matching EVV PCS Visit Found," means no matching visit was found (MA Bulletin 05-21-04, October 22, 2021). The bulletin states that "providers must have matching EVV visit(s) for the service detail billed."

A visit can be verified in EVV and still exceed the authorization, or be within the authorization and still lack enough EVV data. Correct the underlying issue in the appropriate system and follow your payer's instructions before resubmitting. Whether a corrected or retroactive authorization resolves an overage depends on the payer and the case.

The practical result: hours worked outside the authorization are hours you paid the caregiver for and may not be able to bill. The usual causes are ordinary ones: a caregiver who stays an extra hour, a schedule copied from last month after the authorization changed, a swap that puts two visits on the same day when frequency allows one.

Recoupments: when payment is taken back

Getting paid is not the end of it. A payer may seek repayment when services cannot be substantiated. Under 55 Pa. Code § 52.64(a)(3), the Department may impose sanctions including "recouping a payment for a service the provider cannot verify as being provided in the amount, duration and frequency billed." Section 52.42(f) adds: "The Department will recoup payments which are not made in accordance with this chapter."

EVV is part of that verification. Since January 1, 2021, DHS denies CHC-MCO PCS encounters "that do not have corresponding visit verifications recorded in the Department's EVV Aggregator" (OLTL Bulletin 07-20-04). Since January 1, 2025, providers must also reach 85% of EVV records verified without manual edits in each program (MA Bulletin 05-24-01). Starting January 2026, providers above 15% manual entries receive alerts from DHS (fee-for-service) or follow-up from their MCO (MA Bulletin 05-25-03), and under the CHC Agreement the MCO must impose "progressive corrective action requirements or penalties" on a provider over the threshold for two or more consecutive quarters.

PHA describes the effect on agencies plainly: "providers have experienced a significant increase in payment recoupments and audit activity, often based on technical documentation deficiencies or interpretations of policy rather than fraud or inappropriate care. These recoupments have resulted in substantial financial losses for providers - frequently after payroll and other operating expenses have already been incurred" (PHA, July 14, 2026).

PHA also notes a specific EVV problem: "Providers are increasingly required to defend valid claims simply because services were delivered in an allowable community setting rather than the participant's residence." If a participant receives services outside the home, document why at the time of the visit, not when the auditor asks.

Authorizations that expire

Authorizations have end dates. When a reauthorization is late, agencies face a choice PHA describes this way: "providers often continue delivering previously authorized services without assurance of reimbursement, assuming the financial burden of delays outside their control." PHA adds that "many software do not allow for EVV without an active service authorization," which means visits during the gap may not even be captured cleanly.

Track authorization end dates and document follow-up with the service coordinator or payer. A practical habit: list every end date at least 30 days out and contact the service coordinator early, noting the date and person for each follow-up. If an authorization expires before an update arrives, confirm the next steps under your payer agreement and agency procedures. Continuing service does not guarantee reimbursement.

The service coordinator also has obligations. Under 55 Pa. Code § 52.26(a)(10), they must "ensure and document at least on a quarterly basis that the participant's services are being delivered in the type, scope, amount, duration and frequency as required by the participant's service plan." Hours that are authorized but not delivered show up in that review.

On "use it or lose it": check the authorization period and your payer's rules. Unused authorized hours do not represent services delivered and should not be billed as though they were. If a participant's needs change, talk to the service coordinator about the service plan.

Retroactive eligibility

Eligibility can change after the visit. PHA reports: "Providers are increasingly required to repay significant sums due to retroactive eligibility terminations, despite verifying eligibility and providing services in good faith" (July 14, 2026).

You cannot control a retroactive termination, but you can show that you checked. Verify eligibility on a fixed schedule (for example, at the start of each month and before each new authorization period), and keep a dated record of each check.

The rate context

Margins in PAS are thin, which is why each of these issues matters. PHA reported a statewide average agency PAS rate of $20.63 per hour, with regional rates from $19.32 (Pittsburgh) to $21.52 (Philadelphia) (PHA testimony to the House Human Services Committee, April 8, 2024). PHA's FY2026-27 funding request says the rate did not change from 2022 to 2025. In its 2026 RFI response, PHA wrote that "the vast majority of CHC-MCOs reimburse providers at or near the minimum allowable rate."

The owner of a Philadelphia agency described what that rate has to cover: "payroll taxes, workers' comp, insurance, training, the ads we place for recruitment, compliance, all the infrastructure for the business" (Philadelphia Tribune, October 4, 2026). With that little room, held units and recoupments come straight out of what is left after payroll.

A weekly CHC checklist for owners

Use this as a starting point and adapt it to your MCO contracts.

Every day - Review HHAeXchange Prebilling for authorization and EVV errors, and fix them in the source system before billing. - Confirm that the next day's visits match each participant's authorized frequency.

Every week - Compare authorized units with scheduled and delivered units for each participant, and review EVV verification as a separate check. - Check your manual-edit rate against the 85% verified-without-edits requirement, by program. - List authorizations ending in the next 30 days and contact the service coordinator for each one. - Review new referrals against the 7-business-day start requirement.

Every month - Verify eligibility for every active participant and keep the record. - Review any recoupment or denial notices for patterns (same caregiver, same participant, same error code). - Confirm that documentation for visits outside the home explains the setting.

Always - Keep supporting documentation for manual EVV entries. The DHS EVV FAQ says: "For any manual entries, however, supporting hard copy documentation should be kept." - Know each MCO's timely filing limits. They are set in your provider agreement, not in a single public rule.

How Concepts Central Support helps

Concepts Central Support works inside HHAeXchange for Pennsylvania agencies, tracking authorized against delivered hours (authorization utilization), building schedules from the service plan (scheduling), and covering evenings and weekends so new starts and call-outs are handled when they happen (after-hours and on-call). Our team comes with 10 years of experience in home care operations. If you want to talk through how your agency handles CHC today, contact us.

Sources

• PA DHS, EVV for Personal Care Services
• PA DHS, EVV FAQ
• PA DHS, 2026 Community HealthChoices Agreement
• 55 Pa. Code § 52.42, Payment policies
• 55 Pa. Code § 52.64, Payment sanctions
• 55 Pa. Code § 52.26, Service coordination services
• OLTL/ODP Bulletin 07-20-04, EVV for Personal Care Services (September 10, 2020)
• MA Bulletin 05-21-04, Updated ESC Descriptions for PCS Subject to EVV (October 22, 2021)
• MA Bulletin 05-24-01, Updated EVV Manual Edits Compliance Percentage Requirements (August 23, 2024)
• MA Bulletin 05-25-03, EVV Manual Edits Noncompliance (August 29, 2025)
• PA Health & Wellness, EVV Communication Effective 10/19/2020
• Keystone First CHC, Personal Assistance Services Start Date Reminder (August 28, 2025)
• HHAeXchange, Pennsylvania Community HealthChoices Provider Information Center
• HHAeXchange, Enterprise Process Guide: Prebilling
• Pennsylvania Homecare Association, Response to the Community HealthChoices RFI (July 14, 2026)
• Pennsylvania Homecare Association, testimony to the House Human Services Committee (April 8, 2024)
• Pennsylvania Homecare Association, testimony to the Senate Democratic Policy Committee (November 10, 2025)
• Pennsylvania Homecare Association and PA HCBS, Program Revision Request FY2026-27
• Philadelphia Tribune, "Pennsylvania home care shortage strains workers, vulnerable residents" (October 4, 2026)