The IHCP Prepares for ACA Provider Screening and Enrollment Changes

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.