Addition of Categorical Risk Level to Provider Taxonomies and Records

Effective Jan. 29, 2023, NCTracks will make system changes to ensure providers are screened appropriately for an adverse background finding indicating the provider could present a risk to the Medicaid program.

Existing and newly applying Medicaid providers will be moved to a high categorical risk level from a limited or moderate categorical risk level when:

(1) The State Medicaid agency imposes a payment suspension on a provider based on credible allegations of fraud, waste or abuse, the provider has an existing Medicaid overpayment, or the provider has been excluded by the Office of Inspector General (OIG) or another State's Medicaid program within the previous 10 years.

(2) The State Medicaid agency or Centers for Medicare and Medicaid Services (CMS), in the previous six months, lifted a temporary moratorium for the particular provider type and a provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider at any time within six months from the date the moratorium was lifted.

If a provider is moved to a higher categorical risk level, a letter will be sent detailing the effective date, end date, reason and screening requirements for the higher risk level. Fingerprinting and site visit screening  may be required for providers who have been moved to a higher risk level. Providers who already have fingerprinting results from within the past five years for all individuals will not be required to complete fingerprinting again.

Please note that due to the system changes, any enrollment, re-enrollment or re-verification applications that are in draft will be deleted on Jan. 29, 2023. Providers are encouraged to submit their drafts prior to this date or wait to begin their application until after implementation.

See Federal Regulation § 455.450 Screening levels for Medicaid providers for more information.