Medicaid Application Revisions Necessary to Comply with New CMS Rule on Affiliations

Tuesday, November 19, 2019

To comply with a final rule issued by the Centers for Medicare and Medicaid Services (CMS), which requires additional disclosures by enrolling providers, revisions to the NC Medicaid Provider Enrollment Application are underway. This final rule, effective Nov. 4, 2019, implements statutory provisions that require providers and suppliers to disclose certain current and previous affiliations with other providers and suppliers.

The final rule implements a provision of the Social Security Act that requires providers and suppliers to disclose any current or previous direct or indirect affiliation with a provider or supplier that has uncollected debt; has been or is subject to a payment suspension under a federal health care program; has been or is excluded by the Office of Inspector General (OIG) from Medicare, Medicaid or Children’s Health Insurance Program (CHIP); or has had its Medicare, Medicaid or CHIP billing privileges denied or revoked. This provision allows for the denial of enrollment based on such an affiliation, when it is determined that the affiliation poses an undue risk of fraud, waste or abuse.

NC Medicaid will publish an announcement when revisions to the enrollment application have been made to allow for the collection of the additional required information pertaining to affiliations.  

(All states must comply with the federal requirements in 42 CFR part 455, subparts B and E, as well as the ‘‘free choice of provider’’ requirement in § 431.51. Under 42 CFR part 455, subpart B, providers and disclosing entities must furnish disclosures regarding ownership and control of the provider or disclosing entity, certain business transactions and criminal convictions related to federal health care programs. It is section 1866(j)(5) of the Act, added by section 6401(a)(3) of the Affordable Care Act, that requires a provider or supplier submitting an enrollment application or a revalidation application for Medicare, Medicaid or CHIP to disclose affiliations as described above.)

GDIT, (800) 688-6696