Provider Enrollment and Screening Requirements FAQs

Enrollment and Screening

Who initiated the new screening and enrollment guidelines?

The Centers for Medicare and Medicaid Services (CMS), under standards established by the Affordable Care Act (ACA), with a focus on strengthening requirements for Medicaid provider screening and other enrollment requirements.

When will the new screening and enrollment guidelines be implemented?

Although indicated in a May 9, 2012 Medicaid Bulletin and letter to State Agencies this would be implemented by August 1, 2012, due to delays a new implementation date will be targeted and communicated to providers in future bulletins. Prior to implementation, provider outreach activities will focus on communication of the new policies and other related information. New screening and enrollment information will be distributed through Medicaid bulletins, SCDHHS website messages and alerts, training and orientation activitiesfor certain programs and updatesto Program Manuals.

What are some of the new provider screening and enrollment guidelines?

Enhanced provider screening and enrollment based on risk categories (limited, moderate and high) for fraud, waste and abuse for each provider type as assigned by CMS and the SCDHHS.
Background checks and unannounced pre and post enrollment site visits
Fingerprint-based criminal history record checks
Updated Disclosure of Ownership and Controlling Interest Statements
Enrollment of ordering/referring providers
Suspension of provider Medicaid payments in cases of credible allegations of fraud
Denial of enrollment and/or termination of a provider from the Medicaid program “for cause”. This is defined as the revocation of Medicaid billing privileges for FAQs: Provider Enrollment and Screening Requirements (12/05/22) 4 specific reasons such as denial/termination from the Medicare program, denial/termination from other state Medicaid and Children’s Health Insurance Programs, or other reasons based on credible allegations of fraud, integrity or quality.
Implementation of a temporary moratorium on new provider enrollments, when instructed by CMS, to protect against high risk of fraud and abuse
Revalidation of enrolled providers at least every five years, with the exception of DME providers, who need to revalidate every three years

Will I have to undergo a criminal background check?

The Centers for Medicare and Medicaid Services, under standards established by the Affordable Care Act, strengthened requirements for Medicaid provider screening in order to prevent fraud, waste and abuse. Effective Aug. 15, 2022, South Carolina Healthy Connections Medicaid providers classified as “high risk level” are required to undergo a fingerprint-based criminal background check.

View the fingerprint-based criminal background check FAQs to learn more about the requirements.

How can I obtain more information regarding the new provider screening and other enrollment requirements?

A link to the Federal Register, Vol 76, No. 22, dated February 2, 2011, can be found on the SCDHHS website at SCDHHS.gov.

Risk Categories

How are providers categorized by risk categories?

Three levels of screening (limited, moderate and high) are recognized for those provider types that are also recognized provider or supplier types under Medicare. For those provider types that are not recognized under Medicare, SCDHHS has assessed the risk of fraud, waste and abuse using similar criteria to those used in Medicare. See the list below for SCDHHS risk categories: Limited Risk: (State-regulated and State-licensed would generally be categorized as limited risk)

Physician or non-physician practitioners and medical groups or clinics (excluding Physical Therapists and Physical Therapists Groups)
Nursing Homes, Hospitals, Public and Private Community Mental Health Centers,
Audiologists, Certified Nurse Midwife/Licensed Midwife, Certified Registered
Nurse Anesthetists, Anesthetist Assistants, CMS Parts A & B, Managed Care
Organizations, Licensed Marriage and Family Therapists, Licensed Professional
Counselors, Licensed Independent Social Workers –Clinical Practice,
Psychologists, Speech Therapists, Nurse Practitioners, Physician’s Assistants,
Occupational Therapists, Physicians, Speech and Hearing Clinics, End Stage Renal FAQs: Provider Enrollment and Screening Requirements (12/05/22) 5
Disease Clinics, DHEC Clinics, Federally Qualified Health Clinics, Federally Funded Health Clinics and Rural Health Centers, Ambulatory Surgical Centers, Diabetes
Education Clinics, School Districts, Developmental Rehabilitation Clinics, Infusion
Centers, Pediatric Aids Clinics, Maternal and Child Health Clinics, Dentists,
Opticians, Optometrists, Podiatrist, Chiropractors, Pharmacy, Pharmacy Part D,
Individual Transportation Providers, Contractual Transportation Providers, Transportation Broker, X-Ray (not portable) Moderate Risk: (Highly dependent on Medicare, Medicaid and CHIP to pay salaries and other operating expenses and which are not subject to additional governmental or professional oversight and would be considered moderate risk)
Rehabilitative Behavioral Health Services, Physical Therapists , Comprehensive Outpatient Rehabilitation Facilities (CORFs), Hospice Providers, Community Long Term Care (individuals and groups)
Independent Laboratories, X-Ray (portable), Ambulance and Helicopter Providers
Currently enrolled (revalidating Home Health Agencies)
Currently enrolled (revalidating DMEPOS) High Risk: (Identified by the State as being especially vulnerable to improper payments and would be considered as high risk)
Proposed (newly enrolling) Home Health Agencies (HHAs), Suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

Will the entities in each screening category stay the same?

CMS will continuously evaluate whether they need to change the assignment of categories of providers and suppliers to various risk categories. If they assign certain groups of providers and/or suppliers to a different category, this change will be proposed in the Federal Register.

Can a provider be moved from one risk category to another?

Yes, providers can be reassigned from the “limited” or “moderate” categories due to:

Imposition of a payment suspension within the previous 10 years
A provider or supplier has been terminated or is otherwise precluded from billing Medicaid FAQs: Provider Enrollment and Screening Requirements (12/05/22) 6
Exclusion by the OIG
A provider or supplier has been excluded from any federal health care program
A provider or supplier has had billing privileges revoked by a Medicaid contractor within the previous 10 years
A provider or supplier has been subjected to a final adverse action (as defined in 42 CFR 424.502) within the past 10 years
Instances in which CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, appliesfor enrollment as a Medicaid provider or supplier at any time within 6 months from the date the moratorium was lifted.

Ordering and Referring Providers

Can a billing provider be an ordering or referring provider as well?: Yes, as long as the provider is not designated as an ordering/referring provider exclusively. Future edits will prevent claims payment if an ordering/referring-only provider submits their NPI as a billing provider.
How can a provider check to see if the ordering/referring physician is enrolled with Medicaid?: On the SCDHHS website SCDHHS.gov, there is a searchable listing of Enrolled Providers under the For Providers tab. If the provider is not listed, then the provider is not currently enrolled with Medicaid. You may also contact the Provider Service Center at 1 (888) 289-0709, option 4 to verify the provider’s enrollment.

Temporary Moratorium

What is a Temporary Moratorium?: A temporary moratorium is the imposition of a hold or freeze on the enrollment of new or initial Medicaid providers and suppliers of a particular provider type or the establishment of new practice locations of a particular provider type in a specific geographic area for a period of six months. CMS may extend a temporary moratorium in six month increments. The announcement of a moratorium will be reported in the Federal Register. FAQs: Provider Enrollment and Screening Requirements (12/05/22) 8
How long does the enrollment process take?: Enrollment applications will be processed within thirty (30) business days from the date of receipt. The thirty (30) business day timeframe may be exceeded for enrollment applicationsthat require: additional information, a site visit, a contractual agreement, or are submitted with sanction information.
How can we get an enrollment status update?: Contact the Provider Service Center (PSC) (888) 289-0709, option 4 for Provider Enrollment. Please have your Reference ID number available.
Why did my enrollment application get rejected after I made the corrections I was told to?: A provider is notified about rejections via the Enrollment Rejection Letter. The rejection letter indicates the reason(s) for the rejection. For further assistance, contact the Provider Service Center at 1 (888) 289-0709, option 4.

Link a Provider to a Group

How do I enroll a new provider who has joined our group?: Individuals can be added anytime to a group without having to pay an application fee. If an individual wants to be added to a group that is not currently enrolled, the group will have to enroll. Once the group is enrolled, the individual must then request to be added to the group. If the individual provider is already enrolled in South Carolina Medicaid, submit in writing an update request to have the provider affiliated with the group. The request must be on business letterhead to include the Group’s Medicaid Legacy ID number and the individual provider’s NPI number with an authorized printed name and signature via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809 Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt. If the individual provider is currently in the process of enrolling, the provider can indicate on the online application the Group’s Medicaid Legacy ID number and NPI number for group affiliation. FAQs: Provider Enrollment and Screening Requirements (12/05/22) 9
Where do I list the individuals affiliated with our group on the enrollment application?: During the online enrollment process, organizations cannot affiliate individuals to their group. It is the responsibility of the individual provider to affiliate with a group. The request must be on business letterhead to include the Group’s Medicaid Legacy ID number and the individual provider’s NPI number with an authorized printed name and signature via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809 Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt.
Why is the group enrollment effective date before the date our individual provider joined the group?: When an individual provider is affiliated with a group, the original group enrollment date remains the same regardless of when the individual provider was affiliated. The individual provider does not receive a new enrollment date when affiliated with the group.
Why didn’t the mailing address also update when I affiliated the individual provider to our group?: Affiliating an individual provider with a group does not automatically update any other information on the individual provider’s record. The request must be in writing if the individual provider’s record information needs updating. Submit the request on business letterhead with an authorized printed name and signature via Fax: (803) 8709022 or Mail: Medicaid Provider Enrollment, PO Box 8809, Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt.

Update Profile

Why can’t we update our enrollment profile over the phone?: SCDHHS requires updates to a provider’s file to be submitted in writing on business letterhead with an authorized printed name and signature. Submit any updated changes via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809, Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt.
How do I update the individual provider’s name?: SCDHHS requires the individual provider to send in a completed/signed W9 form with the individual’s name, SSN, address and signature. Providers are also required to complete the Disclosure of Ownership and Control Interest Statement Form. FAQs: Provider Enrollment and Screening Requirements (12/05/22) 10

Claims

Will my claims from two weeks ago process if I just enrolled today?: Upon approval of enrollment (the provider has met all necessary requirements); the enrollment date of the provider’s effective date will retroactively begin 90 days prior to the date of receipt of the application. However, depending on the provider’s type/specialty, if the provider is required to sign a contractual agreement in addition to the provider enrollment agreement, the enrollment date isthe effective date of the contract. Note: Medicaid will not pay for claims prior to an enrollment effective date or before the provider’slicensure/certification date.
Why are our claims denying for dates of service prior to the individual provider leaving the practice?: Prior to requesting the removal of an Individual provider from your group practice ensure that the pending claims are adjudicated. However, if the provider has already been removed from the group prior to the claim(s) being adjudicated and needs to be added back to the group, submit the request on the business letterhead with the provider’s or an authorized signature via Fax: (803) 870-9022 or Mail: Medicaid Provider Enrollment, PO Box 8809, Columbia, SC 29202-8809. Updates will be processed within ten (10) days of receipt.