Federal regulations required DHCS/ Medi-Cal to begin screening providers for enrollment based upon risk categories. Though effective 1/1/ 2013, DHCS has now finalized which provider types are in each categorical risk level of "limited", "moderate", or "high". Providers that fit within more than one risk level must be screened at the highest applicable level.
Federal regulations further require the Medi-Cal program to conduct specific screening measures based on an applicant's/provider's categorical risk level. Provider types designated as "limited" categorical risk are subject to license verification and database checks. Provider types designated as "moderate" categorical risk are subject to on-site inspections, in addition to all screening measures applicable to "limited" risk provider types. Provider types designated as "high" categorical risk are subject to criminal background checks and fingerprinting in addition to all screening measures applicable to "limited" and "moderate" risk provider types.
DHCS is also allowed to rely on the results of the provider screening performed by Medicare contractors and the Medicaid or Children's Health Insurance Program (CHIP) programs of other states within the previous 12 months. Consequently, moderate-risk and high-risk applicants/providers may not be required to undergo additional screening if they submit verification of screening completed within the previous 12 months by a Medicare contractor or Medicaid or CHIP program of another state. For applicants/providers that have completed screening and have been approved by a Medicare contractor or another state's Medicaid or CHIP program, DHCS may accept as verification an official dated notice for the enrolling agency that specifies the applicant's/provider's legal name and physical business address.
Pharmacies providers are considered limited risk. DME providers who are newly enrolling are considered high risk. An existing DME provider who is only revalidating enrollment is in the moderate risk category.
