42 CFR §455.450 requires State Medicaid agencies to screen all initial applications, including applications for a new practice location, and any applications received in response to a re-enrollment or revalidation of enrollment request based on a categorical risk level of “limited,” “moderate,” or “high.”  If a provider could fit within more than one risk level described in this section, the highest level of screening is applicable.

Risk Levels

Providers are categorized by limited, moderate or high risk level. This determination is made by CMS, based on an assessment of potential for fraud, waste and abuse for each provider type.

Providers enrolling, revalidating or changing ownership will be screened according to their assigned risk level.

General screening activities required for each risk category:

Risk Level: Limited

Screening Activities: Verification of provider-specific requirements, including but not limited to the following:

1. License verification
2. National Provider Identifier check
3. Database Exclusion Check

Provider types not listed in the moderate or high categories below are in the limited category.

Risk Level: Moderate

Screening Activities: Verification of provider-specific requirements, including but not limited to:

1. License verification
2. National Provider Identifier check
3. Database Exclusion Check
4. Unannounced site visits   

Providers in the moderate category:

• PT 30 – Community Mental Health Center   
• PT 34 – Home Health Agency (at Revalidation)
• PT 37 – Independent Lab
• PT 44 – Hospice   
• PT 55 – Ambulance Service Supplier   
• PT 56 – Ambulance (Specialty 661 only)   
• PT 86 – Other Lab/X-ray   
• PT 87 – Physical Therapist
• PT 90 – DME (at Revalidation)
• PT 91 – Comprehensive Outpatient Rehabilitation Facility

Risk Level: High

1. License verification
2. National Provider Identifier check
3. Database Exclusion Check
4. Fingerprinting and criminal background check for all individuals with five percent or greater ownership in the entity
5. Unannounced site visits

Providers in the high category:

• PT 34- Home Health (newly enrolled)   
• PT 90- Durable Medical Equipment (DME) (newly enrolled)