​ 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)
  
• PT 12 - Nursing Facility (newly enrolled) 
  
• ​The screening risk level in 42 CFR ​§ 424.518 for Skilled Nursing Facilities (SNF) changed effective Jan. 1, 2023. SNFs enrolling or undergoing a change in ownership have been elevated from the "limited" level of categorical screening to the "high" screening level. The final rule prompting this change was published in the Federal Register on Nov. 18, 2022 (87 FR 69404). Any SNF newly enrolling, undergoing a change in ownership, or that reports a new owner on or after Jan. 1, 2023, is required to be screened at the "high" screening level, resulting in the owner(s) being fingerprinted. Revalidating SNFs (so long as they are not reporting a change in ownership) fall under the "moderate" screening level. 
  
• PT 44 - Hospice (newly enrolled) ​
  
• ​The screening risk level for hospices has been elevated from the "moderate" to "high" level effective Jan. 1, 2024. Hospice providers enrolling or undergoing a change in ownership shall be elevated from the "limited" level of categorical screening to the "high" screening level. The final rule prompting this change was published in the Federal Register on Nov. 13, 2023 (88 FR 77​676​). As a result, any Hospice provider that newly enrolls, undergoes a change in ownership, or reports a new owner on or after Jan. 1, 2024, is required to be screened at the "high" screening level, resulting in the owner(s) being fingerprinted. Revalidating Hospice providers (so long as they are not reporting a change in ownership) fall under the "moderate" screening level.