Each Indiana Health Coverage Programs (IHCP) provider is subject to preenrollment screening. Providers are categorized by risk level – limited, moderate or high – using the Centers for Medicare & Medicaid Services (CMS) guidelines for risk determination. The IHCP Provider Enrollment Risk Category and Application Fee Matrix provides a full list of provider types and their CMS-assigned risk levels, both for enrollment and revalidation. Please note that the risk level assignment of an individual provider may be increased at any time at the discretion of the IHCP. In these instances, the provider is notified by the IHCP, and the new risk level will apply to processing enrollment-related transactions.
Providers enrolling, revalidating or changing ownership are screened according to their assigned risk levels. The following table outlines the general screening activities required for each risk level.
Note: Risk-level assignments do not apply to practitioners enrolling as ordering, prescribing or referring (OPR) providers.
Screening Activities Required for Each Risk Level
Screening Activity* | Limited Risk | Moderate Risk | High Risk |
|---|---|---|---|
License verification | X | X | X |
National Provider Identifier (NPI) check | X | X | X |
Office of the Inspector General (OIG) exclusion check | X | X | X |
Ownership/controlling interest information verification | X | X | X |
Other database checks – System Award Management (SAM), Social Security Death Master List, Provider Termination database | X | X | X |
Unannounced site visits before and after enrollment/revalidation | X | X | |
Fingerprint background check for all individuals with 5% or more ownership or a controlling interest in the entity | X |
* Screening criteria depend on provider-specific requirements and therefore vary by provider type. Screening is not defined by or limited to this list of activities in all instances.
Fingerprint Background Check
Providers assigned to the high-risk category are required to have a national fingerprint background check. This requirement applies to all individuals who have at least 5% ownership or controlling interest in the enrolling business entity, including the board of directors if the enrolling entity is not-for-profit. The requirement also applies to individual practitioners who have been assigned to the high-risk category.
- The background check requires affected individuals to submit to fingerprinting. For the IHCP to conduct the background check, fingerprinting must be submitted through the Indiana State Police. Each affected individual must take the following steps:
- Individuals who can be fingerprinted in the state of Indiana should follow the Instructions for Fingerprinting If Using a Location in Indiana.
- Individuals who are not able to be fingerprinted in the state of Indiana should follow the Out-of-State Fingerprinting Instructions.
- To be fingerprinted, providers will need a valid photo ID.
- At the point fingerprints are taken, a confirmation number will be provided. Be sure to record the confirmation number, as this information will be needed when completing the IHCP provider enrollment application.
- Individuals who have had a fingerprint-based federal background check done for the IHCP within the last six months do not need to repeat the process for a new enrollment; the confirmation number of the prior printing will be acceptable as long as the background check was conducted within six months of submission.
- The individuals will be responsible for the cost of the fingerprinting.
- It is important to follow instructions carefully, or it may be necessary to be refingerprinted.
Fingerprints will be submitted for state and federal background checks. Results will determine whether the provider is eligible to participate as an IHCP provider based on criteria in the following sections of this webpage.
Note: Background check results from a different state agency cannot be used to satisfy this requirement.
Indiana Background Evaluation Criteria
The Indiana Family and Social Services Administration (FSSA), Office of Medicaid Policy and Planning (OMPP), may deny or terminate an individual's or entity's eligibility to participate as a Medicaid provider in the state of Indiana if the agency finds that the provider or a person owning, directly or indirectly, at least 5% of the enrolling/enrolled entity has been convicted of any offense (including guilty pleas and adjudicated pretrial diversions) that the agency determines is inconsistent with the best interest of IHCP members or the Medicaid program.
The following list includes examples of offenses that may demonstrate that a provider is not eligible for participation. This list is not exhaustive:
- Felony crimes against persons, such as murder, rape, assault and other similar violent crimes
- Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other crimes of criminal neglect, misconduct or fraud
- A criminal offense that may subject members to an undue risk of harm
- Sexual misconduct that may subject members to an undue risk of harm
- A crime involving a controlled substance
- Abuse or neglect of a child or adult
- A crime involving the use of a firearm or other deadly weapon
- Crimes directly related to the provider's ability to provide services under the Medicaid program
Scoring Criteria for High-Risk Providers
The following documents outline the scoring criteria for high-risk providers:
- OMPP Criminal History Scoring Criteria for High-Risk Providers – Home Health, Durable Medical Equipment (DME) and Waiver Services
- OMPP Criminal History Scoring Criteria for High-Risk Providers – Transportation
Notes:
Out-of-state and federal felony, misdemeanor, and infraction convictions; pending charges; and charges in active deferral will be treated in the same manner as in-state convictions and charges, as set forth in the scoring criteria documents.
Indiana offenses not found in Articles 9 and 35 of the Indiana Code (IC) will be treated in the same manner as the offences set forth in the scoring criteria documents.