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Provider Enrollment Information
 
Risk Level Classification by Provider Type

ForwardHealth has begun working toward ACA compliance by implementing some new provider requirements and provider screening processes.

In accordance with ACA, ForwardHealth has implemented new risk level classifications assigned by provider type. The risk level classifications have been established by the Centers for Medicare and 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.

Providers should note that the provider type is how the provider is enrolled with Wisconsin Medicaid. Provider types are broken down 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).

Risk Level Classifications

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

  • Limited.
  • Moderate.
  • High.

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 must have onsite visits before and after enrollment to be compliant with the CMS final rule §455.432. ForwardHealth automatically screens all enrolling and enrolled providers monthly using federal databases. Additionally, ForwardHealth verifies that providers' licenses are in accordance with applicable state laws and that there are no current limitations on the license. High risk providers need to submit fingerprints and undergo criminal background checks prior to enrollment.

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

  • ForwardHealth imposes a payment suspension on a provider based on a credible allegation of fraud or if the provider has been excluded by Medicare or another state's Medicaid program within the last 10 years.
  • If in the previous six months, ForwardHealth or CMS lifted a temporary moratorium for a particular provider type and a provider that was prevented from enrolling, due to the moratorium, applies for enrollment at any time within six months from the date the moratorium was lifted.

Refer to this chart detailing the screening activities for each risk level. Refer to this chart of risk level classification by provider type and specialty.

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

Providers should note that the risk level classification they are assigned may be subject to change at any time.

Revalidation

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 screening activities.

 
 
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