IHCP Prepares for ACA Provider Screening and Enrollment Changes

IHCP Prepares for ACA Provider Screening and Enrollment Changes

In compliance with the requirements of the Affordable Care Act (ACA), the Indiana Health Coverage Programs (IHCP) has made significant changes to provider enrollment policies and procedures effective January 1, 2012. Details about the changes have been published recently in BT201151 (October 18, 2011), BT201154 (November 15, 2011), and BT201155 (November 15, 2011).

Major changes include:

  • Providers are categorized by risk level - high , moderate, or limited. This categorization is established by the Centers for Medicare & Medicaid Services (CMS), based on an assessment of potential for fraud, waste, and abuse for each provider type. The Provider Type Application Fee and Risk Assignment Matrix (for Non-Waiver and Waiver providers) shows a full list of provider types by risk level.
  • Providers will be screened according to the assigned risk level. The following table outlines the general screening activities required for each risk category:
Risk Level Screening Activities
High
  • Fingerprinting and criminal background check for all disclosed individuals
  • Unannounced site visits before and after enrollment
  • Verification of provider-specific requirements, including:
    • License verification
    • National Provider Identifier (NPI) check
    • Office of the Inspector General (OIG) exclusion check
    • Ownership/controlling interest information verification
Moderate
  • Unannounced site visits before and after enrollment
  • Verification of provider-specific requirements, including:
    • License verification
    • NPI check
    • OIG exclusion check
    • Ownership/controlling interest information
Limited
  • Verification of provider-specific requirements, including:
    • License verification
    • NPI check
    • OIG exclusion check
    • Ownership/controlling interest information verification
  • Certain providers will be subject to an application fee of $523. CMS sets the application fee, which may be adjusted annually. The fee is assessed at initial enrollment and at enrollment revalidation, and is charged individually and in full for each service location. If a provider pays an application fee to Medicare or to another state Medicaid agency for a service location, the provider is not required to pay an additional application fee for that location to the IHCP. The application fee applies to "institutional" providers, as defined by CMS. Generally, application fees do not apply to individual professionals, such as physicians. Will providers be required to pay application fees when their enrollments change or are revalidated? The Provider Type Application Fee and Risk Assignment Matrix (for Non-Waiver and Waiver providers) on the Provider Enrollment page of indianamedicaid.com shows a full list of providers, by type and specialty, that are subject to application fees.
  • All enrolled providers must be revalidated at least every five years. Under current policy, providers have not been required to re-enroll on a regular basis. Providers enrolling on or after January 1, 2012, however, will be required to revalidate their enrollments with the IHCP at five-year intervals. A more frequent three-year revalidation requirement applies to durable medical equipment (DME) providers and pharmacy providers with DME or home medical equipment (HME) specialty enrollments. All providers enrolled before January 1, 2012, must also revalidate their enrollments under ACA criteria. Beginning in the spring of 2012, the IHCP plans to revalidate existing providers in phases, with completion scheduled for December 31, 2014.

To meet federally mandated requirements, the IHCP will change provider enrollment forms and processes. The Provider Enrollment pages on indianamedicaid.com will undergo significant revisions related to the changes. Important dates for for implementing these changes follow:

  • December 1, 2011 (postmarked date) - The last date providers could submit provider enrollment applications and updates on the old forms. Enrollment applications and updates postmarked after December 1, 2011, using the "current" or "old" forms will not be processed and will be returned to the provider.
  • December 21, 2011 - The date new forms and provider enrollment guidance post to indianamedicaid.com. Providers will be directed step by step through the new requirements for enrollment documentation and screening.
  • January 2, 2011 (postmarked date) - The first date the IHCP will accept enrollment applications and updates using the new forms. All enrollment applications and updates received using the new forms will be subject to the new provider screening and enrollment requirements.

Have questions? Please review the ACA Provider Screening and Enrollment FAQs.