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.

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.

For 2015, SCDHHS must collect a $553 application fee from business organizations and entities that are enrolling in South Carolina Medicaid with an Employee Identification Number (EIN). [Note: $542 for 2014.] The fee is to be used to cover the cost of program integrity efforts including the cost of screening associated with provider enrollment processes. This fee can vary from year to year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CIP-U). The application fee will be imposed on business organizations and entities that are enrolling in South Carolina Medicaid that are: (1) initially enrolling, (2) adding a practice location and (3) revalidating enrollment information at least every five years (with the exception of DME providers, who must revalidate every three years). Providers that are EXEMPT from the application fee are: individual physicians or non-physician practitioners.

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 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, Orthothics and Supplies (DMEPOS)

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. 

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

For 2015, SCDHHS must collect a $553 application fee prior to executing a provider agreement whether upon an initial enrollment, reactivation, revalidation or an enrollment to add a new practice location. [Note: $542 for 2014.] The provider enrollment application fee is applicable to providers that the Centers for Medicare & Medicaid Services (CMS) has identified as institutional providers.  South Carolina Healthy Connections Medicaid recognizes and enrolls the following institutional providers:  Ambulatory Surgery Centers, Community Mental Health Centers; Comprehensive Outpatient Rehabilitation Facilities; Durable Medical Equipment, End Stage Renal Disease Facilities; Federally Qualified Health Centers; Home Health Agencies; Hospices; Hospitals, Acute Inpatient Facilities, Inpatient Psychiatric Facilities, Inpatient Rehabilitation Facilities, Independent Clinical Laboratories; Skilled Nursing Facilities and Rural Health Clinics.

The fee is to be used to cover the cost of program integrity efforts including the cost of screening associated with provider enrollment processes. This fee can vary from year to year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CIP-U). A provider will be exempt from the fee if they have submitted and received approval for a Hardship Waiver request or they can demonstrate they are enrolled or have paid the application fee to Medicare and/or another state’s Medicaid or CHIP for the same enrollment location jurisdiction.  A different enrollment jurisdiction means “a new enrollment with an address different from a currently enrolled location.”  Individual physicians (sole proprietors enrolling with an EIN and Social Security Number (SSN) are considered individuals), non-physician practitioners and non-physician practitioner organizations are exempted from paying the enrollment application fee.

• 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.
• Institution of application enrollment fees for business organizations and entities that are enrolling with South Carolina Medicaid with an Employee Identification Number (EIN).
• 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.