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
  • 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, applies for enrollment as a Medicaid provider or supplier at any time within 6 months from the date the moratorium was lifted.

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