The IHCP Prepares for ACA Provider Screening and Enrollment
Changes
To become compliant with the Affordable Care Act (ACA)
requirements, the Indiana Health Coverage Programs (IHCP) announced
in BT201151, dated October 18, 2011, significant changes to
provider enrollment policies and procedures effective January 1,
2012.
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) provides a full list of provider types by
assigned risk level.
- Providers will be screened according to their 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 (including those with ownership
interest of 5% or greater and those with operational or managerial
control of the applying entity)
- Unannounced site visits before and after enrollment
- Verification of provider-specific requirements, including the
following:
- 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 the
following:
- License verification
- NPI check
- OIG exclusion check
- Ownership/controlling interest information verification
|
| Limited |
- Verification of provider-specific requirements, including the
following:
- 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 amount, 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 you be required to pay an application fee when
your enrollment is changed or revalidated? The Provider Type
Application Fee and Risk Assignment Matrix (for
Non-Waiver and
Waiver providers) provides a full list of providers, by type
and specialty, that are subject to application fees.
- Enrollment forms will collect additional
information. Updated IHCP enrollment forms will require
additional information for all disclosed individuals.
Additional information includes dates of birth and Social Security
numbers.
- 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 enrollment 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.
Questions? Please review the ACA Provider
Screening and Enrollment FAQs and look for additional guidance
in upcoming bulletins, banner pages, and website
postings.