DHHS Internet Website - Medicaid & Long-term Health Care

Nebraska Medicaid Program

  Provider Screening and Enrollment

Click to subscribe

Section 6401 of the Affordable Care Act mandates new provider screening and enrollment requirements that State Medicaid agencies must implement. The requirements can be found in 42 CFR 455 Subpart E-Provider Screening and Enrollment.  Nebraska Medicaid must implement these requirements to comply with Federal law.  These requirements apply to all providers.  Current providers will be required to revalidate their agreements.

Federal Register http://www.gpo.gov/fdsys/pkg/FR-2011-02-02/pdf/2011-1686.pdf

1. Fees

All newly enrolling, reenrolling, and reactivating institutional providers, including providers enrolled as groups, are required to pay an application fee. The Centers for Medicare and Medicaid Services (CMS) determines what the application fee is each year. The fee for 2012 is $523.

• The fee is not required to be paid to Nebraska Medicaid if the provider is already enrolled in Medicare, or has paid the fee to Medicare or another state Medicaid program

2. Licensure

Verification of provider license in any state the provider is licensed, including a determination of whether the license has any restrictions.

3. Risk Level

All provider types must be assigned a risk level based on the increased risk each provider type poses for committing fraud, waste, or abuse against the Medicaid program.

1. CMS determines risk levels for all Medicare provider types.

2. If a provider could fit into more than one risk level, the highest level of screening is applicable.

3. Risk level must be raised to high when any of the following occurs:

1. The state Medicaid agency imposes a payment suspension on a provider based on a credible allegation of fraud

2. The provider has an existing Medicaid overpayment

3. The provider has been excluded by the OIG or another state’s Medicaid program within the last 10 years

4. The state Medicaid agency or CMS lifted a temporary moratorium for a particular provider type within the previous 6 months.

4. Screening activities:

1. Limited Risk

1. Federal database checks of providers and any person with an ownership or control interest or who is an agent or managing employee of the provider

1. Social Security Death Master File

2. National Plan and Provider Enumeration System

3. Office of Inspector General List of Excluded Individuals and Entities

4. Excluded Parties List System

2. Moderate Risk

1. Federal database checks (listed above)

2. Unannounced pre- and post-enrollment site visits

3. High Risk

   1. Federal database checks (listed above)

   2. Unannounced pre- and post-enrollment site visits

   3. Conduct criminal background check of the provider and any person with a 5% or more direct or indirect ownership control

   4. Require the submission of a set of fingerprints by the provider and any person with a 5% or more direct or indirect ownership control

4. Denial and Termination

The Department must deny or terminate from participation in Nebraska Medicaid the enrollment of any provider if

1. Any person with a 5% or greater direct or indirect ownership interest in a provider does not submit timely or accurate information and cooperate with any screening methods

2. Any person with a 5% or greater direct or indirect ownership interest in a provider has been convicted of a criminal offense related to that person’s involvement in Medicare, Medicaid, or title XXI in the last 10 years

3. The provider has been terminated from Medicare or another state’s Medicaid program

4. The provider, or a person with ownership or controlling interest, or who a managing employee of the provider fails to submit timely or accurate information

5. The provider, or any person with a 5% or greater direct or indirect ownership interest in a provider fails to submit fingerprints as determined