You delivered the care in Pennsylvania. Did all of it turn into a clean, paid claim?
Between Community HealthChoices, the Sandata aggregator, HHAeXchange, and a 180-day filing clock, some of it never turned into a clean, paid claim. Reeve helps you find where, read-only, before the window closes.
Every dollar a Pennsylvania personal-care agency earns passes through four columns that are supposed to agree. In practice they drift, and the gaps between them are where earned margin quietly leaks.
What the payer approved. In Pennsylvania that is mostly Community HealthChoices (CHC), the managed long-term services and supports program run through the CHC managed care organizations, plus fee-for-service OLTL and OMAP for the populations still billed that way. Your authorization lives in the plan of care and the service authorization.
The visit that actually happened, captured by Electronic Visit Verification. Pennsylvania runs an open EVV model. Fee-for-service PCS flows through the PA-DHS Sandata EVV system and the PA-DHS Aggregator. CHC managed care runs on HHAeXchange, which interfaces with the state aggregator. If you serve both populations, you are live on both.
The claim you actually submitted, on Pennsylvania personal-care codes. Agencies here commonly bill the state-specific W1793 for personal assistance and companion services under CHC, and the national T1019 fifteen-minute personal-care unit, depending on payer and program. Your own fee schedule and MCO manual govern which code, unit, and modifier apply.
What the payer remitted after its edits ran.
Reeve reconciles these four columns against each other on an export you provide, names coded in your own browser first, and shows you the specific records where they disagree. It reads. It does not write, does not file a claim, and does not move money.
- 01No visit, no pay. Since July 1, 2020, Pennsylvania DHS denies PCS claims that have no corresponding visit recorded in the PA-DHS EVV Aggregator. A visit that failed to reach the aggregator, or matched to the wrong authorization, is delivered care that will not pay until the match is fixed.
- 02The manual-edit exposure. Effective January 1, 2025, Pennsylvania holds providers to an EVV compliance standard, and in 2026 DHS issues alerts when a provider exceeds a 15% manual-edit threshold for the prior quarter. Two consecutive quarters of noncompliance can trigger a corrective action plan and sanctions.
- 03The 180-day clock. A Pennsylvania Medical Assistance original claim must reach the department within 180 days of the date of service. A rejected original claim can be resubmitted within 365 days. Delivered visits that stall in an EVV exception queue can age past 180 days while nobody is watching the calendar.
- 04Authorized-but-under-billed hours. Care delivered inside the authorization that was never billed, or billed for fewer units than the record shows, capped at the authorized ceiling.
These figures are illustrative and synthetic. They are method, not results. Reeve never invents a rate. Dollars come from the rate on your own export or the rate your own remittances actually paid most often. Where Reeve cannot find a rate in your data, the finding comes to you in hours, units, and the exact records. A rate Reeve has not verified is a rate Reeve will not quote. For Pennsylvania, Reeve reports the hours, units, and records where the four columns disagree, and you value them against your own contracted rate sheet.
Why an annual audit or the EMR alone misses this.
Your EMR is very good at the job it was built for. It schedules the visit, holds the authorization, and produces the claim. It is not built to sit across from the payer remittance and the EVV aggregator at the same time and tell you, visit by visit, where authorized, delivered, billed, and paid stopped agreeing.
The EVV-to-claim seam. Fee-for-service care runs through Sandata and the PA-DHS Aggregator, managed care runs through HHAeXchange, and a claim only pays when the visit matched cleanly in the right system. A visit that failed to match is invisible in a normal billing report until the denial comes back, if anyone connects the denial to the original visit at all.
The 180-day clock. An annual audit finds the leak in month eleven. Pennsylvania stops paying original claims at day 180. By the time a yearly review runs, a real share of what it finds is already past the filing window and past the 365-day resubmission window too. A reconciliation you can run on today's export is the difference between a finding you can act on and a finding you can only mourn.
A yearly look tells you what happened. Reeve shows you what is still recoverable.
Plain answers, on the record.
Straight answers on how Reeve works with Pennsylvania home care, EVV, and the filing clock.
- 01Which EVV system does Pennsylvania use for home care?
- Pennsylvania uses an open EVV model. Fee-for-service personal care services run through the PA-DHS Sandata EVV system feeding the PA-DHS Aggregator. Community HealthChoices managed care runs on HHAeXchange, which interfaces with the state aggregator. Agencies may use an alternate EVV vendor as long as it captures the required data and interfaces with the PA-DHS Aggregator.
- 02Can a Pennsylvania Medicaid claim be denied for an EVV mismatch?
- Yes. Since July 1, 2020, Pennsylvania DHS denies personal care services claims that have no corresponding visit recorded in the PA-DHS EVV Aggregator. Delivered care that did not match cleanly will not pay until the visit is verified and reconciled.
- 03What is the timely-filing window for Pennsylvania Medical Assistance?
- An original Pennsylvania Medical Assistance claim must be received by the department within 180 days of the date of service. A rejected original claim may be resubmitted within 365 days of the date of service. Certain exceptions exist for pending eligibility or third-party denials.
- 04What is the manual-edit threshold Pennsylvania is enforcing?
- Pennsylvania holds providers to an EVV compliance standard effective January 1, 2025, and in 2026 DHS issues alerts when a provider exceeds a 15% manual-edit threshold for the prior quarter. Two consecutive noncompliant quarters can trigger a corrective action plan and potential sanctions.
- 05What procedure codes do Pennsylvania home care agencies bill for personal care?
- It depends on program and payer. Agencies commonly bill the Pennsylvania-specific W1793 for personal assistance and companion services under Community HealthChoices, and the national T1019 fifteen-minute personal-care code in some cases. Your own fee schedule and MCO billing manual govern the correct code, unit, and modifier.
- 06Does Reeve tell me the dollar amount I can recover in Pennsylvania?
- No, and here is why plainly. Reeve never invents a rate. Where Reeve cannot find a rate in your data, the finding still comes to you in hours, units, and the exact Pennsylvania records where the four columns disagree, with the dollar figure left to your own rate sheet.
- 07Does Reeve touch my patient data or my billing system?
- No. The Margin Review runs read-only on an export you provide, names coded in your own browser before any analysis. Your file is processed in your browser, and no name is written into any output. Reeve reads and hands the worklist back to your biller.
Collect is money you never captured. Cover is money a payer can still take back.
Reeve reports the two separately and never adds them together, because only one of them is yours to go and get. The Margin Review reads both on your own export and costs nothing.
One pass over your own export, in your browser. The findings are yours to keep, with no obligation.
The recovery lane. Care you delivered and never billed, units short of what was authorized, lines paid under the published rate.
Everything in Collect, plus the exposure lane. Retired codes, authorizations at the end of their period, care delivered past what was approved.
Month to month, no annual contract. Read-only in every tier. Run the free review.
Try it yourself. Run a free Margin Review.
Run a free, read-only Margin Review on your own export. It reconciles what Pennsylvania authorized against what you delivered, billed, and got paid, and shows you the exact visits and units where they stopped agreeing. No sales call required to see the first finding.
- 01
Read-only. Reeve reads an export you provide. It does not write to your EMR, does not file or edit a claim, and does not move money.
- 02
Names coded first, in your browser. Client names, member IDs, and caregiver names are replaced with a coded reference locally before any math runs.
- 03
Every number on this page is illustrative and labeled. Reeve never invents a rate; dollars come from the rate on your own export or the rate your own remittances actually paid most often.
- 04
Reeve is arm's-length software, built by operators and engineers. You earned this margin in Pennsylvania. This just helps you make sure you keep it.
Any dollar figures in examples are illustrative and synthetic, method rather than results.