Provider Management

Provider management module includes processes (initial and ongoing) to screen and enroll providers into Medicaid, as well as to keep provider information current and to provide data to authorized requesters. Provider outreach and communications, as well as responding to provider requests and issues, are included.

CMS-Required Outcomes (21)

Ref	Outcome	Sources
PM11 Risk Level Assignment	A state user can assign and screen all applications by a risk categorization of limited, moderate, or high for a provider at the time of new application, re-enrollment, or re-validation of enrollment. A state user can adjust a provider's risk level due to payment suspension or moratorium.	42 CFR 455.450
PM17 Fraud	A state user can report required information about fraud and abuse to the appropriate officials.	42 CFR 455.17
PM18 Payment Suspension	The system, or a state user, can suspend payment to providers in cases of fraud.	42 CFR 455.23
PM1 Application	A provider can initiate, save, and apply to be a Medicaid provider.	42 CFR 455.410(a)
PM2 Screening	A state user can view screening results from other authorized agencies (Medicare, CHIP, other related agencies) to approve provider if applicable.	42 CFR 455.410(c)
PM3 Screening	A state user can verify that any provider purporting to be licensed in a state is licensed by such state and confirm that the provider's license has not expired and that there are no current limitations on the provider's license ensure valid licenses for a provider.	42 CFR 455.412
PM4 Revalidation	The system tracks the provider enrollment period to ensure that the state initiates provider revalidation at least every five years.	42 CFR 455.414
PM5 Termination	A state user (or the system, based on automated business rules) must terminate or deny a provider's enrollment upon certain conditions (refer to the specific regulatory requirements conditions in 42CFR455.416).	42 CFR 455.416
PM6 Reactivation	After deactivation, a provider seeking reactivation must be re-screened by the state and submit payment of associated application fees before their enrollment is reactivated.	42 CFR 455.420
PM7 Appeal	A provider can appeal a termination or denial decision, and a state user can monitor the appeal process and resolution including nursing homes and ICFs/IID.	42 CFR 455.422
PM8 Site Visits	A state user can manage information for mandatory pre-enrollment and post-enrollment site visits conducted on a provider in a moderate or high-risk category.	FR 455.432(a)
PM9 Background Checks	A state user can view the status of criminal background checks, fingerprinting, and site visits for a provider as required based on their risk level and state law.	42 CFR 455.434
PM10 External Systems Checks	The system checks appropriate databases to confirm a provider's identity and exclusion status for enrollment and reenrollment and conducts routine checks using federal databases including: Social Security Administration's Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), and the Excluded Parties List System (EPLS). Authorized users can view the results of the data matches as needed.	42 CFR 455.436
PM12 Application Fees	The system can collect application fees. A state user ensures any applicable application fee is collected before executing a provider agreement.	42 CFR 455.460
PM13 Moratoria	A state user can set CMS and state-imposed temporary moratoria on new providers or provider types in six-month increments.	42 CFR 455.470
PM14 Network Adequacy	A state user can determine network adequacy based upon federal regulations and state plan.	42 CFR 438.68
PM15 Sanctions and Terminations	A state user, and/or the system, can send and receive provider sanction and termination information shared from other states and Medicare to determine continued enrollment for providers.	42 CFR 455.416(c)
PM16 Notices and Communications	The system can generate relevant notices or communications to providers to include, but not limited to, application status, requests for additional information, re-enrollment termination, investigations of fraud, suspension of payment in cases of fraud.	42 CFR 455.23
PM19 Agreements and Disclosures	A state user can view provider agreements and disclosures as required by federal and state regulations.	42 CFR 455.104 42 CFR 455.105 42 CFR 455.106 42 CFR 455.107
PM20 Change in Circumstances	A state user can view information from a managed care plan describing changes in a network provider's circumstances that may affect the provider's eligibility to participate in Medicaid, including termination of the provider agreement.	42 CFR 438.608(a)
PM21 Directory	A beneficiary can view and search a provider directory.	42 CFR 438.10(h)