The reports and checks may be mailed regular or certified mail to MIVS, Attn: Benefit Recovery – Credit Balance Reporting, P.O. Box 8355, Columbia, SC 29202-8355 or may be sent by facsimile to MIVS, Attn: Benefit Recovery – Credit Balance Reporting, 803-462-2582.

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

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.

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.

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.

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)

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. 

Providers that submit inaccurate or incomplete information will be notified of the rejected credit balance report. The provider will be instructed to re-submit another report for the applicable quarter.

The Medicaid Credit Balance Report is not replacing the current credit balance reviews performed by other reviewing agencies. Providers are not to report other agencies’ identified claims on the Medicaid Credit Balance Report - this may cause possible duplication of claim recoupment. Providers impacted by such reviews need to continue their current procedure in responding to any correspondence received from other agencies’ credit balance reviews.