New Medicaid Provider Enrollment And Revalidation Requirements

One of the changes brought about by the Affordable Care Act (ACA) is the enhanced enrollment and revalidation screenings for providers and suppliers not only under Medicare but also Medicaid and CHIP healthcare programs.

Medicaid Enrollment Requirement

Providers and suppliers, except those who are members of risk-based managed care organizations, are now required to be enrolled in the state Medicaid programs if they continue to order or refer services reimbursed by fee-for-service (FFS) Medicaid, even if they themselves do not submit claims for reimbursement to Medicaid. The New York State Medicaid Program also imposes this enrollment requirement on all “attending” practitioners.

Additionally, all claims for payment for ordered or referred items or services must include the NPI of the ordering or referring physician. According to the Centers for Medicare & Medicaid Services (CMS), “[i]f the NPI is not provided on claims for payment or the ordering or referring provider is not enrolled in the Medicaid program, States must deny such claims.” CMS further advises that if an NPI of the ordering/referring physician is provided on the claim but the provider is not enrolled in Medicaid, “States may pend a claim from the provider performing the services which were ordered or referred to allow for the ordering/referring provider to become enrolled and after such enrollment pay the claim.”

Enhanced Medicaid Provider Screening

Federal regulations now also require that all Medicaid providers be screened upon initial application, when applying for a new practice location, and upon re-enrollment and revalidation, on a categorical risk level basis which mirrors the enhanced screening requirements now in effect for Medicare providers.

The risk levels for screening Medicaid providers are: “limited,” “moderate,” or “high.” (Compare 42 C.F.R. 424.518, imposing risk categories on Medicare providers, with, 42 C.F.R. 455.450, imposing risk categories on Medicaid providers). If a certain provider type is not recognized under Medicare, CMS “expects” States to “access the risk of fraud, waste and abuse using similar criteria to those used in Medicare, as outlined in Federal Register, Vol. 76, dated February 2, 2011…”

The Federal regulations further provide that if a Medicaid provider could fit within more than one risk level, then “the highest level of screening is applicable.” In performing provider screenings, States are permitted to rely on the screening results obtained by Medicare and other state agencies. Federal regulations also allow State Medicaid agencies to impose screening methods that are more stringent than those established by the Federal government.

In meeting the requirements under the ACA, State Medicaid agencies are required to, among other things, do the following:

  1. License – verify that a provider purporting to be licensed in accordance with the laws of any State is licensed by such State and confirm that the provider’s license has not expired and that there are no current limitations on the provider’s license;
  2. Revalidation – all Medicaid providers must be revalidated by March 24, 2016.  State Medicaid agencies must also continue revalidation of Medicaid providers, regardless of provider type, at least every five years;
  3. Termination – State agencies must terminate the enrollment of any provider where any person with a 5% or greater direct or indirect ownership interest in the provider did not submit timely and accurate information and cooperate with any screening methods;
  4. Denial – State agencies must deny enrollment or terminate the enrollment of any provider where any person with a 5% or greater direct or indirect ownership interest in the provider has been convicted of a criminal offense related to that person’s involvement with the Medicare, Medicaid, or title XXI program in the last 10 years, unless the State Medicaid agency determines that denial or termination of enrollment is not in the best interests of the Medicaid program and the State Medicaid agency documents that determination in writing;
  5. Denial – State agencies must deny enrollment or terminate the enrollment of any provider that is terminated on or after January 1, 2011, under title XVIII of the Act or under the Medicaid program or CHIP of any other State;
  6. A State agency may terminate or deny the provider’s enrollment if CMS or the State Medicaid agency (1) determines that the provider has falsified any information provided on the application; or (2) cannot verify the identity of any provider applicant.

New York State Medicaid Program Response To Physician Enrollment/Ordering Requirement

The New York Medicaid Program announced several exemptions from the ordering/referring/attending provider requirement, which include: (1) Medicaid managed care and family health plus encounters and services reimbursed by the plans; and (2) services ordered/referred by residents and other practitioners that NYS Medicaid FFS does not authorize to enroll (these latter claims must include the NPI of the enrolled supervising physician).

The New York Medicaid program will soon have system enhancements that will allow servicing providers to verify the enrollment status of ordering/referring/attending physicians. For now, servicing providers may (1) contact the order/referring/attending provider; (2) check remittance advice for specific claims edits that will assist providers in identifying non-enrolled ordering/referring/attending providers; or (3) contact Computer Science Corporation at 800-343-9000 for more information.

New Jersey State Medicaid Program Response To Physician Enrollment/Ordering Requirement

While the New Jersey’s Medicaid Program, administered by the New Jersey Division of Medical Assistance and Health Services within the Department of Human Services, has yet to comment specifically on the requirement of having the ordering/referring/attending provider be enrolled in Medicaid, it has discussed other ACA enhanced enrollment and revalidation requirements that will be addressed in our future article.

If you have questions about provider Medicare or Medicaid enrollment or revalidation requirements, the New York State or New Jersey Medicaid Programs, or need other legal assistance, please contact us.