Provider Risk Level Adjustment

Note: This article was originally published in the May 2018 Medicaid Bulletin.

Federal regulation 42 CFR 455.450 requires a state Medicaid agency to screen all initial provider applications based on a categorical risk level of "limited," "moderate," or "high." This includes applications for new practice locations and any applications received in response to a re-enrollment or re-validation of enrollment request.

Providers are categorized by risk level as outlined in NC General Statute Sec. 108-C3, as amended by Session Law 2018-5 SB 99.

Note: The NCTracks Provider Permission Matrix provides a full list of provider types and their assigned risk levels for both enrollment and revalidation.

Further, 42 CFR 455.450(e) mandates that state Medicaid agencies adjust the categorical risk level of providers. Per NC General Statute Sec. 108-C3(g) and amended by Session Law 2018-5 SB 99, the N.C. Department of Health and Human Services (the "Department") must adjust the categorical risk level to "high" for providers who:

• Received a payment suspension based upon a credible allegation of fraud in accordance with 42 CFR 455.23 within the previous 12-month period. The Department shall return the provider to its original risk category no later than 12 months after the cessation of the payment suspension.
• Were excluded, or whose owners, operators, or managing employees were excluded, by the U.S. Department of Health and Human Services Office of Inspector General, the Medicare program, or another state's Medicaid or Children’s Health Insurance Program within the previous 10 years.
• Incurred a Medicaid or Health Choice final overpayment, assessment, or fine from the Department more than 20 percent of the provider's payments received from Medicaid and Health Choice in the previous 12-month period. The Department shall return the provider to its original risk category not later than 12 months after the completion of the provider's repayment of the final overpayment, assessment, or fine. (NC General Statute 108-C3(g) (11))
• Were convicted of a disqualifying offense pursuant to G.S. 108C-4, including by owners, operators, or managing employees, but were granted an exemption by the Department within the previous 10 years.

In these instances, the provider will be notified by the Department and the new risk level will apply to processing enrollment-related transactions. This may include payment of applicable application fees, submission of fingerprints and onsite visits.

Providers with questions can contact the CSRA Call Center at 1-800-688-6696 (phone), 1-855-710-1965 (fax) or NCTracksProvider@nctracks.com.