CMS Releases Bulletin to States Regarding New Medicaid Provider Screening and Enrollment Requirements

January 3, 2012

CMS has issued a bulletin to states with guidance on new protocols for screening and enrollment of Medicaid and CHIP providers. These requirements are posted in the Federal Register, 42 CFR Part 455 subpart E, and were published on February 2, 2011 following the approval last spring of proposed regulation CMS 6028.

In a recently issued a bulletin addressing Medicaid and CHIP Provider Screening and Enrollment, CMS established a deadline of April 1, 2012 for states to provide assurance of compliance with new federal regulations.

These guidelines, designed to improve provider integrity, were initially published in the Federal Register on February 2, 2011 as part of the Patient Protection and Affordable Care Act (PPAC). They went into effect for new providers in March 2011, and will go into effect for existing providers beginning in March 2012. States have until March 24, 2016 to complete a re-validation process in accordance with these new guidelines that needs to occur every five years for all provider types. New providers, who enrolled after March 25, 2011, must be re-validated within five years of enrollment.

LEA questions about state implementation of these CMS guidelines primarily concern the use of National Provider Identification (NPI) numbers. Since organizational providers such as LEAs claim Medicaid reimbursement through an institutional NPI number, the need for individual staff NPI numbers remains unclear. Specific direction is needed as to whether organizational providers must track an additional individual NPI number for staff who refer and order health services. Among other concerns, such a requirement is likely to pose labor issues for schools.

The National Alliance for Medicaid in Education (NAME) has started collecting state-specific information on the implementation of CMS provider guidelines for LEAs. Paradigm will continue to post new information to the Policy Center as it is made available, including implementation details for California.