A risk category is assigned to all providers. The category may be the same or higher than the risk category assigned by Medicare.
Providers have the option to be a Medicaid only provider or a Medicare and Medicaid provider. For Medicaid-only providers, AHCCCS is responsible for assigning the risk category.
AHCCCS has the discretion to adjust the risk level for a provider or provider type based on the following:
Imposition of a payment suspension on a provider based on a credible allegation of fraud, waste, or abuse;
The provider has an existing Medicaid overpayment;
The provider has been excluded by the United States Department of Health and Human Services Office of Inspector General or another State's Medicaid program within the previous 10 years; or
At least 6 months following the lifting of a temporary moratorium for a particular provider type that was impacted by the moratorium.
Provider screening activities are based on the assigned risk level. The table below describes what screening activities are required for each risk level. The risk level for each provider type can be found on the Provider Enrollment Screening Glossary.
|
Risk Level |
Screening Required |
|
Limited |
|
|
Moderate |
|
|
High |
|
In general, proof used to assess risk level may include:
GAO or OIG final reports
Insight of law enforcement partners
Congressional testimony
Level of administrative enforcement actions for a particular provider type
Assessment of the level of state and federal oversight for a particular provider type
Assessment of the level of oversight by accrediting bodies
Aggregate experience with a particular provider type
42 CFR 455.450
42 CFR § 424.518