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.