MedicaidDocumentationMedium impact
Nursing facility ineligible reassessment and certification forms (MA570)
UPMC Health Plan·PA·Education
We identified it
Jun 20, 2026
Summary
Community HealthChoices Medicaid patients require renewal of eligibility for home- and community-based services through completion of the MA570 Pennsylvania Physician Certification Form. Providers must complete and return the form within 14 days to prevent disruption in patient services and Medicaid eligibility.
Action Required
Within 14 days of receipt: Providers must complete the MA570 Pennsylvania Physician Certification Form in its entirety, including patient's level of care designation (NFCE, NFI, or ICF/ORC) and complete page 2 for ICF/ORC patients. Forms must be signed by MD or DO and returned to chcscentral@upmc.edu via secure email or faxed to 1-844-890-7458. Failure to complete forms within 14 days will cause delays in patient applications and potential disruption of Medicaid services.