1. A. Pursuant to the provisions of the Patient Protection and Affordable Care Act (PPACA), Public Law 111-148, 42 CFR Part 455, Subpart E, and the 21st Century Cures Act, the Medicaid Program adopts the following provider enrollment and screening requirements. The Centers for Medicare and Medicaid Services (CMS) has established guidelines for provider categorization based on an assessment of potential for fraud, waste, and abuse for each provider type. The Medicaid Program shall determine the risk level for providers and will adopt these federal requirements in addition to any existing requirements. Providers must comply with all applicable federal regulations and state requirements for their provider type prior to enrollment with the Medicaid Program. Additional enrollment requirements may be adopted in the future.

2. B. In accordance with PPACA and federal regulations, the Medicaid Program shall screen all initial applications, including applications for a new practice location, and any applications received in response to a re-enrollment or revalidation, utilizing the following guidelines. If a provider could fit within more than one risk level described in this section, the highest level of screening is applicable.

   1. 1. Provider types shall be categorized by the following risk levels:

      1. a. high categorical risk—categories of service that pose a significant risk of fraud, waste, and abuse to the Medicaid Program;
      2. b. moderate categorical risk—categories of service that pose a moderate risk of fraud, waste, and abuse to the Medicaid Program;
      3. c. limited categorical risk—categories of service that pose a minor risk of fraud, waste, and abuse to the Medicaid Program.

3. C. Screening activities for the varying risk levels shall include the following mandates.

   1. 1. High risk level screening activities shall include:

      1. a. fingerprinting submission by the provider and any person with a 5 percent or more direct or indirect ownership interest in the provider, within 30 days upon request from CMS or the Department of Health (LDH);
      2. b. criminal background checks for all disclosed individuals;
      3. c. site visits before and after enrollment by LDH and/or CMS, its agents, or designated contractors; and

      4. d. verification of provider-specific requirements including, but not limited to:

         1. i. license verification;
         2. ii. national plan and provider enumeration system (NPPES) national provider identifier (NPI) registry check;
         3. iii. Office of Inspector General (OIG) exclusion check;
         4. iv. disclosure of ownership/controlling interest information;
         5. v. the Social Security Administration’s death master file (SSA DMF) check;
         6. vi. Medicaid and Children’s Health Insurance Program (CHIP) state information sharing system (MCSIS) check;
         7. vii. systems for award management (SAM) check;
         8. viii. LA adverse actions check; and
         9. ix. provider enrollment, chain, and ownership system (PECOS) check.

   2. 2. Moderate risk level screening activities shall include:

      1. a. site visits before and after enrollment by LDH and/or CMS, its agents, or designated contractors; and

      2. b. verification of provider-specific requirements including, but not limited to:

         1. i. license verification;
         2. ii. NPPES NPI check;
         3. iii. OIG exclusion check;
         4. iv. disclosure of ownership/controlling interest information;
         5. v. SSA DMF check;
         6. vi. MCSIS check;
         7. vii. SAM check;
         8. viii. LA adverse actions check; and
         9. ix. PECOS check.

   3. 3. Limited risk level screening activities shall include, but are not limited to:

      1. a. verification of provider-specific requirements including:

         1. i. license verification;
         2. ii. NPPES NPI check;
         3. iii. OIG exclusion check;
         4. iv. disclosure of ownership/controlling interest information verification;
         5. v. SSA DMF check;
         6. vi. MCSIS check;
         7. vii. SAM check;
         8. viii. LA adverse actions check; and
         9. ix. PECOS check.

4. D. The Medicaid Program may rely on, but is not limited to, the results of provider screenings performed by:

   1. 1. Medicare contractors;
   2. 2. other Medicaid agencies; or
   3. 3. CHIP of other states.
5. E. Updated Medicaid enrollment forms may require additional information for all disclosed individuals.
6. F. Providers shall be required to revalidate their enrollments with the Medicaid Program at a minimum of five year intervals. A more frequent revalidation requirement, a minimum of three year intervals, shall apply to durable medical equipment (DME) providers and pharmacy providers with DME or home medical equipment (HME) specialty enrollments. All providers shall be required to revalidate their enrollment under PPACA and Medicaid criteria.

7. G. Provider Screening Application Fee

   1. 1. In compliance with the requirements of the PPACA and 42 CFR §455.460, the department shall collect an application fee for provider screening prior to executing provider agreements from prospective or re-enrolling providers other than:

      1. a. individual physicians or non-physician practitioners; or

      2. b. providers who:

         1. i. are enrolled in title XVIII of the Social Security Act;
         2. ii. are enrolled in another state's title XIX or XXI plan; or
         3. iii. have paid the applicable application fee to a Medicare contractor or another state.
   2. 2. The department shall return the portion of all fees collected which exceed the cost of the screening to CMS.
8. H. After deactivation of a provider enrollment number for any reason, before the provider’s enrollment may be reactivated, the department must re-screen the provider and require payment of associated provider application fees.
9. I. Any enrolled provider is subject to CMS, its agents, its designated contractors, or the department conducting unannounced on-site inspections of any and all provider locations.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 39:1051 (April 2013), amended by the Department of Health, Bureau of Health Services Financing, LR 44:920 (May 2018), LR 50:978 (July 2024).