• 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.

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.

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 activities for certain programs and updates to Program Manuals.

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. 

Yes, a provider will be notified via certified mail when terminated for cause. The provider does have appeal rights.

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.

The HIIRF can be faxed to Medicaid Insurance Verification Services at (803) 252-0870.