The following Q&A comes from the Centers for Medicare & Medicaid Services website. It concerns where newly-enrolling and revalidating providers and suppliers will be placed in one of three screening categories — limited, moderate, or high. These categories represent the level of risk for fraud, waste and abuse to the Medicare program for the particular category of provider/supplier, and determine the degree of screening to be performed by the Medicare Administrative Contractor processing the enrollment application. This took effect March 25.
Q: Which categories of providers are in which level of screening?
CMS: Providers/suppliers in the "limited" screening category will include:
o Physicians
o Non-physician practitioners other than physical therapists
o Medical groups or clinics
o Ambulatory surgical centers
o Competitive Acquisition Program / Part B Vendors
o End-Stage Renal Disease facilities
o Federally-Qualified Health Centers
o Histocompatibility laboratories
o Hospitals (including Critical Access Hospitals, Department of Veterans Affairs hospitals, and other federally-owned hospital facilities)
o Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act
o Mammography screening centers
o Mass immunization roster billers
o Organ procurement organizations
o Pharmacies that are newly enrolling or revalidating via the CMS-855B application
o Radiation Therapy Centers
o Religious non-medical health care institutions
o Rural Health Clinics
o Skilled Nursing Facilities
Providers in the "moderate" screening category will include:
o Ambulance service suppliers
o Community Mental Health Centers (CMHCs)
o Comprehensive Outpatient Rehabilitation Facilities (CORFs)
o Hospice organizations
o Independent clinical laboratories
o Independent Diagnostic Testing Facilities (IDTFs)
o Physical therapists enrolling as individuals or as group practices
o Portable x-ray suppliers (PXRS)
o Revalidating Home Health Agencies (HHAs)
o Revalidating DMEPOS suppliers
Providers in the "high" screening category will include:
o Newly-enrolling DMEPOS suppliers
o Newly-enrolling HHAs
Providers and suppliers reassigned from the "limited" or "moderate" categories due to triggering events. Triggering events include the following instances:
o imposition of a payment suspension within the previous 10 years;
o a provider or supplier has been terminated or is otherwise precluded from billing Medicaid;
o exclusion by the OIG;
o a provider or supplier has had billing privileges revoked by a Medicare contractor within the previous 10 years and such provider/supplier is attempting to establish additional Medicare billing privileges by enrolling as a new provider or supplier or establish billing privileges for a new practice location;
o a provider or supplier has been excluded from any federal health care program;
o a provider or supplier has been subject to any final adverse action (as defined in 42 CFR 424.502) within the past 10 years; or
o instances in which CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicare provider or supplier at any time within 6 months from the date the moratorium was lifted.
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