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Medicaid Provider Enrollment and Validation
The Affordable Care Act (42 CFR Part 455, subpart E) requires the State Medicaid Agency, Department of Human Services, Med-QUEST Division (MQD) to perform more comprehensive screening, credentialing and enrollment for all Medicaid providers in effort to enhance Medicaid fraud prevention. Providers are identified as “high”, “moderate” and “limited” risk levels. The 21st Century Cures Act has set a compliance deadline of January 1, 2018 for these requirements.
To comply with the requirements, MQD is required to:
- Obtain a new Medicaid Provider Application (DHS 1139) from Medicaid providers upon initial enrollment and every five (5) years thereafter in accordance with 42 CFR §455.414. This applies to both existing and new providers.
- Collect an application fee of $500 from institutional providers, including all HCBS providers. This applies to both existing and new providers.
- Conduct on-site visits to high and moderate risk levels providers following receipt of the DHS 1139 form. The purpose of the site visit will be to verify that the information submitted to MQD on the DHS 1139 form is accurate and to determine compliance with Federal and State enrollment requirements.
- For high risk providers, obtain a fingerprint-based criminal background check for everyone who has 5% or more ownership (direct or indirect) of the business. The fitness determination includes a set of fingerprints, Adult Protective Services (APS) and Child Abuse and Neglect Check (CAN) screenings.