Provider Categorical Risk Level Adjustment

This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care. 

State Medicaid agencies are required by 42 CFR 455.450 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 reenrollment or revalidation request. Providers are categorized by risk level consistent with Medicare in accordance with 42 CFR 424.518, or as outlined in NC General Statute Sec. 108-C3.

NC Medicaid is required to adjust a provider’s categorical risk level from “Limited” or “Moderate” to “High” when any of the circumstances listed below occur. Known as Bump-Up, this adjustment to a provider’s categorical risk level means:

1. The additional screenings required of the “High” risk level (site visit and fingerprinting) must be completed to maintain participation with North Carolina Department of Health and Human Services (NCDHHS) programs. 
2. An Off-Cycle Revalidation must be completed two years after the initial Bump-Up. Once this off-cycle revalidation is completed, the provider will return to the usual five-year revalidation cycle. 

The Bump-Up provider will receive notification with additional information and instructions regarding the completion of fingerprinting and site visit. This may include payment of applicable application fees. 

1. Action is required to initiate the fingerprinting process. Follow the instructions in the notification.
2. The site visit will be initiated by NC Medicaid through Public Consulting Group (PCG), who will contract the provider to schedule a visit.

Failure to complete these additional screenings by the specified due date will result in termination from all NCDHHS programs.

For all provider types, the following circumstances require Bump-Up to “High” categorical risk:

• Under 42 CFR 455.450(e), State Medicaid Agencies must adjust the categorical risk level of providers when:
  • Per NCGS 108C-3, a payment suspension is imposed based upon a credible allegation of fraud, waste or abuse. The provider remains “High” risk for 10 years beyond the date of payment suspension. 
  • A provider, owner, operator or managing employee was excluded by the U.S. Department of Health and Human Services Office of Inspector General, the Medicare program or a State Medicaid Program within the previous 10 years. The provider remains “High” risk for 10 years beyond the effective date of the exclusion.
  • An enrolling or revalidating provider has an existing Medicaid overpayment of $1500 or greater that is unpaid for more than 30 days old and not under appeal. The provider remains “High” risk for while the overpayment is outstanding.
  • Centers for Medicare & Medicaid Services (CMS) or the State Medicaid Agency (SMA) in the previous six months lifted a temporary moratorium for a particular provider type and a provider was prevented from enrolling based on that moratorium. This applies for enrollment at any time within six months from the date the moratorium was lifted.
     
• North Carolina General Statute (NCGS) 108C-3(g) designates providers as “High” categorical risk when:
  • A provider, owner, operator or managing employee was convicted of a disqualifying offense pursuant to NC G.S. 108C‑4 but was granted an exemption by the Department and allowed to enroll, within the previous 10 years.

For provider types recognized by NC Medicaid but not Medicare, the following circumstances require Bump-Up under NCGS 108C-3(g) to “High” categorical risk:

• The Department has imposed a payment suspension based upon a credible allegation of fraud in accordance with 42 C.F.R. § 455.23 within the previous 12‑month period. The provider returns to its original risk category not later than 12 months after the cessation of the payment suspension.
• The provider has incurred a Medicaid final overpayment, assessment or fine to the Department in excess of 20% of the provider's payments received from Medicaid in the previous 12‑month period. The provider returns 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.

Additional Resources:

NCTracks Fingerprinting FAQ page

Contact

• NCTracks Call Center: 800-688-6696
• Provider Ombudsman: 866-304-7062