Frequently Asked Questions
Frequently Asked Questions
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What are some of the new provider screening and enrollment guidelines?
How are providers categorized by risk categories?
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:
(State-regulated and State-licensed would generally be categorized as limited 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)
(Identified by the State as being especially vulnerable to improper payments and would be considered as high risk)
Will the entities in each screening category stay the same?
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.
Can a provider be moved from one risk category to another?
Yes, providers can be reassigned from the “limited” or “moderate” categories due to:
What is a Temporary Moratorium?
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.
Will a provider be notified if they are terminated “for cause” and do they have appeal rights?
Yes, a provider will be notified via certified mail when terminated for cause. The provider does have appeal rights.
Where do I send in my credit balance report?
Where can I find the Medicaid Credit Balance Report forms?
Can a billing provider be an ordering or referring provider as well?
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.
How can a provider check to see if the ordering/referring physician is enrolled with Medicaid?
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.