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CMS Provider Screening Requirements & Out-of-State Medicaid Claims

The New Year is here and it’s time for families to start traveling. With travel, come patients from out-of-state. With out-of-state patients, come out-of-state Medicaid claims.

All states have their own rules and regulations regarding Medicaid. But on March 25, 2011 the Centers for Medicare & Medicaid Services (CMS) implemented additional screening requirements for states to follow for Medicaid provider enrollment. If these requirements are not met, the provider risks termination from the Medicaid program and/or a delay in reimbursements.

How Do CMS Provider Screening Requirements Effect Out-of-State Medicaid Claims?

Here are the top 6 requirements, which can be found in the Federal Register, that effect the out-of-state Medicaid enrollment and billing process:

1.) Database Checks

Requirement: States are required to screen all providers “upon initial enrollment and monthly thereafter for as long as the provider is enrolled in the Medicaid program” (p. 5897).


2.) Unscheduled & Unannounced Site Visits

Requirement: The Secretary may carry out unscheduled and unannounced site visits. “States must conduct pre-enrollment and post-enrollment site visits for those categories of providers the State designates as being in the “moderate” or “high” level of screening.” Providers must permit the on-site visits (p. 5898-5899).


3.) Provider Enrollment & Provider Termination

Requirement: All providers must undergo screening at least once every 5 years. States are required to deny or terminate the enrollment of providers if:

  1. The provider “does not submit timely and accurate disclosure information or fails to cooperate with all required screening.”

  2. The provider is “terminated on or after January 1, 2011 by Medicare or any other Medicaid program or CHIP.”

  3. The “provider fails to submit sets of fingerprints within 30 days of a State agency or CMS request.”

States can also deny enrollment to a provider “if the provider has falsified any information on an application or if CMS or the State cannot verify the identity of the applicant” (p. 5900).


4.) Criminal Background Checks & Fingerprinting

Requirement: Each provider the State designates as within the “high” level of screening is subject to fingerprinting (p. 5901).


5.) Deactivation & Reactivation of Provider Enrollment

Requirement: Medicaid providers who have “not submitted any claims or made a referral that resulted in a Medicaid claim for a period of 12 consecutive months” must have their Medicaid provider enrollment deactivated (p. 5903).


6.) Enrollment & NPI of Ordering or Referring Providers

Requirement: The State “must require all ordering or referring physicians or other professionals to be enrolled under a Medicaid State plan or waiver of the plan as a participating provider.” Their NPI must be on applications to enroll and on all claims for payment (p. 5903).


The CMS regulations established more consistency in the screening process so that states can better ensure providers are qualified to serve the Medicaid population. However, since the CMS provider screening requirements were enacted, many providers have been discouraged to seek out-of-state Medicaid reimbursement because of the amount of work involved in the application process. Plus, on top of these standardized enrollment requirements, states vary in their rules and regulations for filing claims.

Don’t Miss Out on Out-of-State Medicaid Revenue


At EligibilityOne, we are experts in out-of-state Medicaid. From CMS provider screening requirements to each state’s individual Medicaid program (and temporary waivers related to COVID-19), we keep track of all rules and regulations that affect out-of-state Medicaid reimbursement.

When you outsource out-of-state Medicaid work to EligibilityOne, you can collect payment for these complex claims without devoting your time and resources to monitoring (ever-changing) federal and state regulations. We will do so for you and take care of every aspect of Medicaid enrollment for both the provider and facility, claims submission, and claims follow-up.

Contact us today to learn more about how we can help your practitioners and facility meet CMS provider screening requirements and obtain reimbursement for your out-of-state Medicaid claims – all at a performance-based rate.



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