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Provider Enrollment Information
 
Risk Level Classification by Provider Type
Risk Level Classifications Are Federally Required

ForwardHealth has implemented provider requirements and provider screening processes to comply with the Affordable Care Act (ACA), such as risk level classifications assigned by provider type. The risk level classifications have been established by the Centers for Medicare & Medicaid Services (CMS), and ForwardHealth has adopted the same guidelines. In cases where provider types are not classified by CMS, ForwardHealth has established the risk level classification.

Risk Level Classifications

All Wisconsin Medicaid-enrolled providers are assigned one of the following three risk levels, based on provider type:

  • Limited
  • Moderate
  • High

Refer to this chart of risk level classification by provider type and specialty.

Note: A provider's assigned risk level classification may be subject to change at any time.

Provider Types and Specialties

The provider type is how the provider is enrolled with Wisconsin Medicaid. Provider types are divided into subtypes, referred to as provider specialty. The specialty refers to services the provider is licensed or qualified to provide. For example, a registered nurse may enroll as a nurse practitioner (provider type) with Wisconsin Medicaid and provide services to members as a midwife (provider specialty).

Screening Requirements Are Based on Risk Level Classification

ForwardHealth performs certain screening activities for each provider during enrollment and again at revalidation, corresponding to the appropriate risk level classification. For example, moderate- and high-risk providers are required to have onsite visits before and after enrollment to comply with the CMS final rule 42 C.F.R. § 455.432. High-risk providers are required to submit fingerprints and undergo criminal background checks prior to enrollment.

Refer to this chart detailing the screening activities for each risk level.

ForwardHealth automatically screens all enrolling and enrolled providers monthly using federal databases. ForwardHealth also verifies that providers' licenses are in accordance with applicable state laws and that there are no current limitations on the license.

Screening Exceptions

If a provider has already been screened by Medicare or another state's Medicaid program or Children's Health Insurance Program in the last 12 months, ForwardHealth will not conduct additional screenings.

Circumstances That Lead to a High Risk Reclassification

To be compliant with CMS final rule 42 C.F.R. § 455.450.e.(2), ForwardHealth will adjust a provider's risk level from "limited" or "moderate" to "high" when one of the following situations occurs:

  • ForwardHealth imposes a payment suspension on a provider based on a credible allegation of fraud.
  • The provider has been excluded by Medicare or another state's Medicaid program within the last 10 years.
  • ForwardHealth or CMS lifted a temporary moratorium for a particular provider type in the previous six months, and a provider that was prevented from enrolling due to the moratorium applies for enrollment within six months from the date the moratorium was lifted.
Revalidation May Reduce a High-Risk Level Classification

Providers who were enrolled at a high-risk level will be revalidated at a moderate-risk level, assuming there were no other circumstances that would constitute the high-risk level. For example, a home health agency that was enrolled at a high-risk level classification will be reassigned a moderate-risk level during revalidation. At the time of revalidation, they will then be screened using the moderate-risk level screening activities.

 
 
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