PROVIDER ENROLLMENT RISK LEVELS AND SCREENING

Each provider is subject to pre-enrollment screening. Providers are categorized by risk level - limited, moderate, or high - using the Centers for Medicare & Medicaid Services (CMS) guidelines for risk determination. The IHCP Provider Enrollment Risk Category and Application Fee Matrix provides a full list of provider types and their CMS-assigned risk levels, both for enrollment and revalidation. Please note that the risk level assignment of an individual provider may be increased at any time at the discretion of the State. In these instances, the provider is notified by the State, and the new risk level will apply to processing enrollment-related transactions.

Providers enrolling, revalidating, or changing ownership are screened according to their assigned risk levels. The following table outlines the general screening activities required for each risk level.

Note: Risk-level assignments do not apply to practitioners enrolling as ordering, prescribing, or referring (OPR) providers.

Screening activity*

Limited risk

Moderate risk

High risk

License verification

X

X

X

National Provider Identifier (NPI) check

X

X

X

Office of the Inspector General (OIG) exclusion check

X

X

X

Ownership/controlling interest information verification

X

X

X

Other database checks -  System Award Management (SAM), Social Security Death Master List, Provider Termination database

X

X

X

Unannounced site visits before and after enrollment/revalidation


X

X

Fingerprinting and criminal background check for all individuals with 5% or more ownership in the entity



X

* Screening criteria depends on provider-specific requirements and therefore, varies by provider type. Screening is not defined by or limited to this list of activities in all instances.

Fingerprinting and Criminal Background Check

Providers assigned to the high-risk category are required to have a national criminal background check. This requirement applies to all individuals who have at least 5% ownership or controlling interest in the enrolling business entity. The requirement also applies to individual practitioners who have been assigned to the high-risk category.

  • The criminal background check requires affected individuals to submit to fingerprinting. For the Indiana Health Coverage Programs (IHCP) to conduct the background check, fingerprinting must be submitted through the Indiana State Police. Each affected individual must take the following steps:
  • To be fingerprinted, providers will need a valid photo ID.
  • At the point fingerprints are taken, a confirmation number will be provided. Be sure to record the confirmation number, as this information will be needed when completing the IHCP provider enrollment application.
    • Individuals who have had a fingerprint-based federal criminal background check done for the IHCP within the last six months do not need to repeat the process for a new enrollment; the confirmation number of the prior printing will be acceptable as long as the background check was conducted within six months of submission.
  • The individuals will be responsible for the cost of the fingerprinting.
  • It is important to follow instructions carefully, or it may be necessary to be re-fingerprinted.

Fingerprints will be submitted for state and federal criminal background checks. Results will determine whether the provider is eligible to participate as an IHCP provider based on the following criteria.

Note: Criminal background check results from a different state agency cannot be used to satisfy this requirement.

Indiana criminal background evaluation criteria

The Indiana Family and Social Services Administration (FSSA), Office of Medicaid Policy and Planning (OMPP), may deny or terminate an individual's or entity's eligibility to participate as a Medicaid provider in the state of Indiana if the agency finds that the provider or a person owning, directly or indirectly, at least 5% of the enrolling/enrolled entity has been convicted of any offense (including guilty pleas and adjudicated pretrial diversions) that the agency determines is inconsistent with the best interest of IHCP members or the Medicaid program.

The following list includes examples of offenses that may demonstrate that a provider is not eligible for participation. This list is not exhaustive.

  • Felony crimes against persons, such as murder, rape, assault, and other similar violent crimes
  • Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud, and other crimes of criminal neglect, misconduct, or fraud
  • A criminal offense that may subject members to an undue risk of harm
  • Sexual misconduct that may subject members to an undue risk of harm
  • A crime involving a controlled substance
  • Abuse or neglect of a child or adult
  • A crime involving the use of a firearm or other deadly weapon
  • Crimes directly related to the provider's ability to provide services under the Medicaid program

Scoring criteria for high-risk providers

The following documents outline the scoring criteria for high-risk providers:

Notes:

Out-of-state and federal felony, misdemeanor, and infraction convictions; pending charges; and charges in active deferral will be treated in the same manner as in-state convictions and charges, as set forth in the scoring criteria documents.

Indiana offenses not found in Articles 9 and 35 of the Indiana Code (IC) will be treated in the same manner as the offences set forth in the scoring criteria documents.