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 records checks.   At the present time, the criminal background checks and fingerprinting are not required. 
  • 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 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.

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