Section 6401 of the Affordable Care Act lists certain Medicaid provider screening and enrollment requirements states must follow. The requirements can be found in 42 CFR 455 Subpart E.
Nebraska Medicaid must follow these requirements to comply with federal law, which applies to all providers. Current providers will be required to revalidate their agreements every five years.
Application Fee
The Centers for Medicare and Medicaid Services (CMS) determines how much the application fee is each year. The fee, paid to Nebraska Medicaid, for 2024 is $709.
All institutional providers, including providers enrolled as groups or agencies, are required to pay an application fee when enrolling, reactivating, and revalidating in the Nebraska Medicaid program.
The fee is not required to be paid if the provider is already enrolled in Medicare, or has paid the fee to Medicare or another state Medicaid program.
Licensure
Each Medicaid program must review the provider license in any state where the provider is licensed. This includes the state determining whether the license has any restrictions. Providers must be licensed to be enrolled and supply services to Nebraska Medicaid clients.
Risk Level
All provider types are assigned a risk level based on the risk each provider type poses for committing fraud, waste, or abuse against the Medicaid program.
Providers enrolled with the Nebraska Medicaid program should also be screening their employees based on the services they provide. More information on provider screening risk levels can be found here.
- CMS determines risk levels for all provider types. Nebraska Medicaid can raise the risk level based on the state's experience with the type of provider.
- If a provider fits into more than one risk level, the highest screening level is applicable.
- The risk level is raised to high when any of the following occurs:
- The state Medicaid program imposes a payment suspension on a provider based on a credible allegation of fraud.
- The provider has an existing Medicaid overpayment of $1,500 or greater.
- The provider has been excluded by the OIG or another state's Medicaid program within the last 10 years.
- The state Medicaid program or CMS lifted a temporary moratorium for a particular provider type within the last 6 months.
- Screening activities:
- Limited Risk
- 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
- Social Security Death Master File
- National Plan and Provider Enumeration System
- Office of Inspector General List of Excluded Individuals and Entities
- System for Award Management
- Moderate Risk
- Federal database checks (listed above)
- Unannounced pre- and post-enrollment site visits
- High Risk
- Federal database checks (listed above)
- Unannounced pre- and post-enrollment site visits
- Fingerprint-based criminal background check of the provider and any person with a 5% or more direct or indirect ownership control
- Require the submission of a set of fingerprints by the provider and any person with a 5% or more direct or indirect ownership control
Denials and Terminations
DHHS must deny or terminate a provider from the Nebraska Medicaid program if:
- 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;
- 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;
- The provider has been terminated from Medicare or another state's Medicaid program;
- The provider, a person with ownership or controlling interest, or a managing employee of the provider fails to submit timely or accurate information; or,
- The provider, or any person with a 5% or greater direct or indirect ownership interest in a provider, fails to submit fingerprints as determined.
Fingerprinting
Provider types that are considered "high risk" must complete a Fingerprint Criminal Background Check during their enrollment. If a provider does not complete the background check within the allotted time, their Medicaid enrollment will be denied or terminated. It is preferred that providers complete this process with the Nebraska State Patrol (NSP). More information on the process can be found in the Fingerprint Criminal Background Check packet.
If you have any questions or need help completing the Fingerprint Criminal Background Check, please contact DHHS.MedicaidProviderEnrollment@nebraska.gov, or (402) 471-9018.
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