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If you’ve been around healthcare long enough, you know how important terminology and understanding acronyms are to grasp how the industry works and the accountabilities of each participant and administrator. By this point, you probably have experienced mixed emotions with all of the complexity and multi-use words for a variety of healthcare authorities and key terms.

Where it really starts to get interesting and challenging is associating how each state describes who is eligible to provide healthcare or not to beneficiaries. Many states provide lists and references for excluded or sanctioned individuals and entities. Those that are excluded can receive no payment from federal healthcare programs for any items or services they furnish, order, or prescribe.

As you will see below, the terminology can vary quite a bit as it pertains to the state Medicaid agencies and departments in charge of program integrity and excluding, precluding, or terminating providers from Medicaid programs. Some states do not have a formal list at all, and you must reference the OIG LEIE and SAM.gov to learn more.


Search each state’s exclusion list below.

Exclusion Source: Alabama List of Suspended Providers

Format: Electronic
Update Schedule: Monthly

Description: 

About Excluded Providers
  • Excluded Individuals and Entities are not allowed to receive reimbursement for providing Medicare and Medicaid services in any capacity, even if they are not on this listing by the Alabama Medicaid Agency.

  • Excluded individuals and entities are listed according to the type of provider they were at the time of exclusion; however, they are excluded from participating in providing services in the Medicaid program in all categories of service and in any capacity. The exclusion remains in effect until they are removed from this list.

  • Any provider participating or applying to participate in the Medicaid program must search Medicaid’s Exclusion List, the List of Excluded Individuals and Entities (LEIE), and the System for Award Management (SAM) website on a monthly basis to determine if any existing employee or contractor has been excluded from participation in the Medicaid program. Also, any provider participating or applying to participate in the Medicaid program must search all three lists prior to hiring staff to ensure that any potential employees or contractors have been excluded from participating in the Medicaid program. For further details on screening of current and potential employees and contractors, see Chapter 7, Section 7.3.1 of the Provider Manual.

  • The Office of the Inspector General maintains a national list of all individuals who are excluded from receiving reimbursement from Medicare and Medicaid. For a comprehensive list of all individuals, go to http://oig.hhs.gov/fraud/exclusions.asp. Additionally, the SAMs website contains a single comprehensive list of individuals and firms excluded by Federal government agencies. This list is located at https://www.sam.gov.

Exclusion Source: Alaska Medical Assistance Excluded Provider List

Format: Electronic
Update Schedule: Monthly

Description: 

Individuals and businesses on the following list are excluded from Alaska Medical Assistance Programs and may also appear on the U.S. Department of Health & Human Services, Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE). Exclusions are the result of criminal, administrative or civil adverse actions and are publicly noticed at the time of exclusion.

EFFECTS of EXCLUSION

• No payment will be made by any federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. Federal health care programs include Medicare, Medicaid, Denali KidCare and all other plans and programs that are federally funded, in whole or in part.

If a payment is found to have been made for services provided by an excluded individual or entity, the payment is considered an overpayment and is subject to recovery under 42 CFR 1001.1901(b). This payment prohibition applies to the excluded person, anyone who employs or contracts with the excluded person, or any hospital or other facility where the excluded person provides services. The exclusion applies regardless of who submits the claims.

• Excluded individuals and entities are published on the Alaska Medical Assistance Excluded Provider List. Although the provider type shown on the list is the provider type the individual or entity was at the time of exclusion, an excluded provider is prohibited from participating or providing services in the Medicaid program in all categories of service. The exclusion remains in effect until the individual is removed from this list.

REMINDER: Before hiring or contracting with an individual or entity, review the Alaska Excluded Provider List and the LEIE. If you find that a current employee or contractor has been included on the Alaska Excluded Provider List or the LEIE, you must contact Program Integrity immediately at Kristina.Harp@alaska.gov or 907.334.2413.

Exclusion Source: Arizona Office of Inspector General – Excluded Providers Confirmation

Format: Electronic
Update Schedule: Monthly

Description:

Learn more about the Arizona Health Care Cost Containment System (AHCCCS).

Exclusion Source: Arkansas Department of Human Services Excluded Provider List

Format: Electronic
Update Schedule: Monthly

Description: 

The Arkansas Department of Human Services Excluded Provider List contains persons, providers, or facilities who are excluded from doing business with the Arkansas Department of Human Services.

The Arkansas Department of Human Services maintains this Excluded Provider List to comply with federal requirements (Medicare and Medicaid Protection Act of 1987 as amended and disqualified schools, institutions and individuals under the Child Nutrition Act, 42 U.S.C. 1760(r)) and pursuant to

DHS Policy 1088 Excluded Providers. This means that a person or provider can be on this DHS Excluded Provider list and yet is not an excluded Medicaid provider and is not a disqualified Child Nutrition provider. DHS Policy 1088 regarding Excluded Providers allows a person or facility to be included on the DHS Excluded Provider List for a variety of reasons outlined in the policy. One reason can be when the person or provider failed, without good cause, to perform or act in accordance with statues, rules, contracts or purchase orders.

Medical providers who are excluded from Arkansas Medicaid must not order, prescribe, or provide services to any clients. Medical providers are liable for all fees paid to them by Arkansas Medicaid for services rendered by excluded individuals and are subject to audits and recoupment of any Medicaid funds paid for services. Medical providers are responsible for checking this list as well as the federal list (located here) upon hiring and periodically thereafter. DHS updates this list regularly in an effort to include all Medicaid Excluded Providers placed on the list by authorized federal or state authorities. If you have an inquiry about the Arkansas Department of Human Services Excluded Provider List, please email (DHS.ExcludedProviders@dhs.arkansas.gov).

Exclusion Source: Medi-Cal Suspended and Ineligible Provider List

Format: Electronic
Update Schedule: Monthly

Description:

Medi-Cal law, Welfare and Institutions Code (W&I Code), sections 14043.6 and 14123, mandate that the Department of Health Care Services (DHCS) suspend a Medi-Cal provider of health care services (provider) from participation in the Medi-Cal program when the individual or entity has:

  • Been convicted of a felony;
  • Been convicted of a misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service;
  • Been suspended from the federal Medicare or Medicaid programs for any reason;
  • Lost or surrendered a license, certificate, or approval to provide health care; or
  • Breached a contractual agreement with the Department that explicitly specifies inclusion on this list as a consequence of the breach.

Suspension of Entities Submitting Claims for Suspended Providers
Suspension is automatic when any of the above events occurs, and suspended Medi-Cal providers will not be entitled to a hearing under the California Administrative Procedures Act.

Services rendered, prescribed or ordered by a suspended Medi-Cal provider shall not be covered by the Medi-Cal program while the suspension is in effect. California Code of Regulations, title 22, section 51303, subdivision (j), provides that at least fifteen (15) days written notice be given to all affected providers. This list constitutes such written notice. Although the period of suspension may have expired, reinstatement rights are not automatic. The provider must petition for reinstatement and re-enroll with DHCS before being reimbursed for services rendered. Providers suspended as a result of a Medicare action must appeal through the Medicare office before applying for re-enrollment with Medi-Cal.

In accordance with W&I Code, section 14043.61, subdivision (a), a provider of health care services shall be subject to suspension if claims for payment are submitted under any provider number used by the provider to obtain reimbursement from the Medi-Cal program for the services, goods, supplies or merchandise provided, directly or indirectly to a Medi-Cal beneficiary, by an individual or entity that is suspended, excluded or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from the Medi-Cal program and the individual or entity is listed on either the Medi-Cal Suspended and Ineligible Provider List (S&I List) published by DHCS to identify suspended and otherwise ineligible providers, or any list published by the federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the federal Medicare and Medicaid programs, to identify suspended, excluded or otherwise ineligible providers.

Examples of providers who need to be aware of the provisions of this law, and could be suspended if violating the law are:

  1. Billing services that submit claims for Medi-Cal providers who are suspended;
  2. Pharmacies that fill prescriptions and bill for services prescribed by a suspended provider;
  3. Providers who bill for services under referral or prescription of a provider who is suspended;
  4. Providers who employ and submit claims for the services of an individual who is a suspended provider;
  5. Physician groups, clinics and institutions that employ and submit claims for the services of an individual who is a suspended provider;
  6. Any individuals or entities that enter into a business arrangement and submit claims for or in conjunction with an individual or entity that is suspended.

Always refer to the S&I List when verifying ineligibility. Eligibility or ineligibility must also be verified through the Health and Human Services (HHS) Federal Office of Inspector General (OIG) List of Excluded Individuals/Entities. Cross-referencing both lists is recommended to help identify providers who have already been suspended or sanctioned. The S&I List is not all inclusive. Temporary sanctions against providers are not included on the web sites. Temporary sanctions that may be imposed include temporary suspensions, withhold of payments and deactivation.

Exclusion Source: Colorado Department of Health Care Policy and Financing (HCPF) Terminated Provider List

Format: Electronic
Update Schedule: Monthly

Description: 

The Department of Health Care Policy and Financing (HCPF) maintains a list of providers whose participation in the Colorado Medicaid program has been terminated for cause. A provider who has been terminated for cause may not receive reimbursement under the Medicaid program. A description of the reasons a provider may be terminated for cause can be found under the definition of Good Cause at 10 CCR 2505-10, Section 8.076.1.7.

Terminated Provider List

Exclusion Source: Delaware Health and Social Services Program Integrity

Format: Electronic
Update Schedule: Monthly

Description:

The Division of Medicaid and Medical Assistance Program Integrity Unit is responsible for activities related to the prevention, detection and investigation of alleged fraud, waste and abuse in the Medicaid program. Program Integrity encourages compliance through education, prevention, audits, third party liability and recovery of improper payments.

Every dollar lost to the misuse of Medicaid benefits, is one less dollar available to fund programs providing essential medical services for the vulnerable citizens of Delaware. Let’s work together to prevent and eliminate fraud, waste and abuse in the Medicaid program.

Exclusion Source: Florida Agency for Healthcare Administration  Sanctioned and Terminated Providers

Format: Electronic
Update Schedule: Monthly

Description:

The Office of Medicaid Program Integrity audits and investigates providers suspected of overbilling or defrauding Florida’s Medicaid program, recovers overpayments, issues administrative sanctions, and refers cases of suspected fraud for criminal investigation.

Sanctioned and Terminated Providers

HHS Excluded Providers (federal database)

Explanation and Disclaimer for Sanctioned, Terminated or Excluded Individuals or Entities [123 KB, PDF]

The Sanctioned providers list contains those providers that were sanctioned or terminated while rendering services for the Medicaid program. The Excluded providers link takes you to the U.S. Department of Health & Human Services Office of Inspector General website where you can search their database of excluded providers. Those excluded providers are individuals and entities who cannot participate in any federal or state funded health care programs.

Exclusion Source: Georgia OIG Exclusions List 

Format: Electronic
Update Schedule: Monthly

Description: 

LIST OF INDIVIDUALS EXCLUDED FROM PARTICIPATING IN THE GEORGIA MEDICAL ASSISTANCE PROGRAM UNDER TITLE XIX OF THE SOCIAL SECURITY ACT OF 1935, AS AMENDED, AND O.C.G.A. §§ 49-4-140 et seq. (THE “MEDICAID PROGRAM”)

What is an Excluded Provider?

DCH-OIG is authorized to exclude certain individuals and entities (providers) from participating in federally funded health care programs, including Medicaid. Excluded individuals and entities are not permitted to receive reimbursement for providing Medicare and Medicaid services in all categories of service and in any capacity, including managed care.

Georgia List of Excluded Individuals/Entities

The Georgia Medicaid Exclusion List below is updated at least monthly.

The excluded individuals and entities are listed in chronological order by the Sanction effective date. All exclusions remain in effect until they are removed from this list.

Disclaimer

DCH-OIG has attempted to ensure that all of the information contained in this list is accurate, to the extent reasonably possible. However, the Agency makes no warranty or guarantee either express or implied concerning the accuracy of the content of the website. No posted information or materials provided are intended to constitute legal or medical advice.

National Exclusion List

For a comprehensive list of individuals and/or entities excluded from receiving reimbursement from Medicare and Medicaid services nationwide, go to: http://oig.hhs.gov/fraud/exclusions.asp (see List of Excluded Individuals and Entities (LEIE).

Please also check the System for Award Management at: https://www.sam.gov/  (formerly the Excluded Parties List System-EPLS).

Medicaid Provider Responsibilities

Any provider participating or applying to participate in the Georgia Medicaid program, including managed care entities, must search the Georgia Medicaid Exclusion List, in addition to the List of Excluded Individuals and Entities (LEIE) and the System for Award Management (SAM) on a monthly basis to determine if any existing employee or contractor has been excluded from participation in the Georgia Medicaid program and/or has been excluded, on a national level, from the Medicare and/or Medicaid program. Furthermore, any provider participating or applying to participate in the Georgia Medicaid program must search all above-referenced lists prior to hiring staff to ensure that any potential employees or contractors have not been excluded from participating in the Medicare and/or Medicaid program.

Providers are required to immediately report to the Department of Community Health, Provider Enrollment Section, any exclusion information discovered among employees or contractors.

Exclusion Source: Hawaii Med-Quest List of Excluded Providers

Format: Electronic
Update Schedule: Monthly

Description: 

 

Details of Excluded Provider List

Excluded individuals and entities are listed according to the type of provider they were at the time of exclusion; however, they are excluded from participating in providing services in the Medicaid program in all categories of service and in any capacity. The exclusion remains in effect until they are removed from this list.

The Office of the Inspector General maintains a national list of all individuals who are excluded from receiving reimbursement from Medicare and Medicaid. For a comprehensive list of all individuals, go to http://oig.hhs.gov/fraud/exclusions.asp.

What is an Excluded Provider?

An excluded provider is an individual or entity that is not allowed to receive reimbursement for providing Medicare and Medicaid services in any capacity, even if they are not on this listing by the Med-QUEST Division. Most exclusions are for a period of three to five years, although exclusion from Medicaid or other federally-funded health care programs can be permanent. The following website gives additional information on the effect of exclusions on participation in federal programs:

The Effect of Exclusion From Participation in Federal Health Care Programs

Medicaid Provider Responsibilities

Any provider participating or applying to participate in the Medicaid program must search Hawaiʻi’s excluded provider list monthly and the List of Excluded Individuals and Entities (LEIE) on an annual basis to determine if any existing employee or contractor has been excluded from participation in the Medicaid program. In addition, any provider participating or applying to participate in the Medicaid program must search both lists prior to hiring staff to ensure that any potential employees or contractors have not been excluded from participating in the Medicaid program.

Exclusion Source: Idaho Medicaid Exclusion List

Format: Electronic
Update Schedule: Monthly

Description: 

Note: This list is not updated on a regular basis. It is updated when an entity or individual is added or reinstated.

The following providers, individuals and entities were excluded by the Idaho Department of Health and Welfare and are excluded from participation in the Idaho Medicaid program. The Idaho Medicaid Exclusion List does not contain information about exclusion action taken by the Department of Health and Human Services Office of Inspector General (HHS-OIG) or other state agencies. Furthermore, state exclusion periods are often different than federal exclusion periods. Therefore, providers must check both the Idaho Medicaid Exclusion List and the HHS-OIG Exclusion List to determine whether a provider, individual, or entity is excluded and, if so, the dates of such exclusion. Information on Medicaid exclusions by other states can be obtained on other state websites or by contacting states where providers, individuals and entities billed. The HHS-OIG Exclusion List is accessed at http://exclusions.oig.hhs.gov.

Federal law prohibits payment for services rendered by state or federally excluded providers, individuals and entities. Moreover, civil monetary penalties may be imposed against any providers who use or contract with excluded providers, individuals or entities to provide items or services to Medicaid participants. Providers are responsible for screening all employees and contractors to identify excluded individuals and are responsible for searching the HHS-OIG website and the Idaho Medicaid Exclusion List monthly to capture exclusions and reinstatements. Providers, individuals and entities are not automatically reinstated at the end of the state or federal exclusion period. If providers, individuals or entities on the state or federal exclusion lists do not have reinstatement dates listed, they are not eligible to provide services.

Exclusion Source: Illinois Department of Healthcare and Family Services OIG Provider Sanctions 

Format: Electronic
Update Schedule: Monthly

Description: 

Provider Sanctions

Summary

Healthcare and Family Services’ authority to impose sanctions on individuals and entities is contained in 305 ILCS 5/12-4.25 and Illinois Administrative Code Section 140.16. Also, individuals and entities voluntarily withdraw from participation in the Medical Assistance Program. The effect of a sanction or voluntary withdrawal is that no program payment will be made for any items or services, including administrative and management services.
Program payment will not be made to any entity in which a listed individual is serving as an employee, administrator, operator or in any other capacity for any services, including administrative and management services furnished, ordered or prescribed on or after the effective date of the sanction or voluntary withdrawal. Also, no payment may be made to any business or facility that submits bills for payment of items or services provided by such an individual or entity.

Disclaimer

The following data file is the most current version provided by Healthcare and Family Services – Office of Inspector General.  All attempts are made to ensure the accuracy of the information. The Department is not liable for any errors or omissions. If a provider reviews the listing to avoid prohibited relationships, as set forth in 89 Illinois Administrative Code, Section 140.16 (a)(8), and the person does not appear on the listing due to omission by the Department, the Department will consider such in enforcement of the Administrative Code.

89 Illinois Administrative Code, Section 140.16 (a)(8)

Such vendor knew or should have known that a person with management responsibility for a vendor; an officer or person owning (directly or indirectly) 5% or more of the shares of stock or other evidences of ownership in a corporate vendor; an investor in the vendor; a technical or other advisor of the vendor; an owner of a sole proprietorship which is a vendor; or a partner in a partnership which is a vendor was previously terminated or barred from participation in the Medical Assistance Program.

Exclusion Source: Indiana Family and Social Services Administration Termination of Provider Participation in Medicaid and CHIP

Format: Electronic
Update Schedule: Monthly

Description:

Federal regulation requires states to provide notice when the enrollment of a Medicaid enrolled provider has been terminated “for cause”. The following list reflects examples of conduct for which provider enrollments may be terminated and meets the definition of “for cause” as defined by CMS. The list is not meant to be exhaustive:

  • Adverse licensure actions
  • Federal exclusion
  • Fraudulent conduct
  • Abuse of billing privileges
  • Misuse of billing number
  • Falsified enrollment information
  • Falsified medical records

Exclusion Source: Iowa Medicaid Provider Sanctions List

Format: Electronic
Update Schedule: Monthly

Description: 

Program Integrity in Iowa Medicaid

Program Integrity is charged with reducing fraud, waste and abuse in the Iowa Medicaid program. Federal legislation under the Deficit Reduction Act (DRA) of 2005 and the Affordable Care Act (ACA) of 2010, as well as S.F. 357 enacted in 2013 by the 85th Iowa General Assembly has provided Iowa Medicaid Program Integrity with the tools and guidance to take action to reduce fraud, waste and abuse in the Medicaid program.  The Iowa Medicaid Enterprise has developed this webpage dedicated to provide you with information and resources related to Medicaid Program Integrity.

  • Iowa Medicaid Provider Sanctions List: The Iowa Code section 249.49 (2013 Acts, ch 24, § 13) directs the Iowa Medicaid Program Integrity Unit to maintain an up-to-date list of providers that are found to be in violation of the Iowa Medicaid Program. This list identifies all providers that the Iowa Medicaid Program Integrity Unit has terminated, suspended, or placed on probation after administrative appeals have been exhausted, all providers that have failed to return an identified overpayment of medical assistance within the time frame specified in Iowa Code section 249A.39, and all providers found liable for a false claims law violation related to the medical assistance program under Iowa Code chapter 685.
  • Medicaid Program Integrity: Toolkits to Address Frequent Findings: 42 CFR 455.104; Disclosures of Ownership and Control: The Centers for Medicare and Medicaid Services (CMS) recently released Medicaid Program Integrity: Toolkits to Address Frequent Findings: 42 CFR 455.104; Disclosures of Ownership and Control Toolkit. The Disclosures of Ownership and Control Toolkit address common issues for states when collecting appropriate disclosures for persons with ownership or control interest. Although managed care entities (MCEs) are not mandated by this federal regulation to obtain ownership and control disclosures from their network providers, CMS considers the requirements under the regulation to be program safeguards that would be prudent to apply in managed care settings.
  • Payment Error Rate Measurement (PERM): Iowa is participating in the Federal Fiscal Year 2014 PERM program. This means that you may be contacted by the CMS national contractor, A+ Government Solutions, Inc., who will collect medical records from you either in hardcopy or electronic format. The medical records request letters will be sent to Iowa Medicaid enrolled providers between June 1, 2014 and August 31, 2014. For more information please review Informational Letters 1340 and 1386. CMS has also supplied a brief educational video describing the PERM review process.
  • Program Integrity: Safeguarding Your Medical Identity Toolkit: The Centers for Medicare and Medicaid Services (CMS) recently released Program Integrity: Safeguarding Your Medical Identity Toolkit. The Safeguarding Your Medical Identity Toolkit materials discuss the scope and definition of medical identity theft, common schemes using stolen identities, consequences for victims, mitigation strategies, and appropriate actions for potential victims of medical identity theft.
  • Program Integrity Provisions of the Affordable Care Act (ACA) for Provider Enrollment and Screening: To improve the program integrity of the Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) programs, the Patient Protection and Affordable Care Act (ACA) requires these programs to screen and enroll all providers associated with the program. For the Iowa Medicaid Enterprise (IME), the new requirements are more extensive than the previous screening procedures and include enrolling providers who were not previously required to enroll in Medicaid.
  • OIG Special Advisory Bulletin: On May 8, 2013 the Office of Inspector General (OIG) issued an updated special advisory bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs. The bulletin provides background and responds directly to frequently asked questions regarding exclusions and the resulting actions.

Exclusion Source: Kansas Terminated Provider List

Format: Electronic
Update Schedule: Monthly

Description: 

What is Medicaid Program Integrity?

Program Integrity is a reasonable and consistent system of oversight of the Medicaid program which effectively encourages compliance; maintains accountability; protects public funds; supports awareness and responsibility; ensure providers meet participation requirements; services are medically necessary; and payments are for the correct amount and for covered services.  The end goal is to reduce and eliminate fraud, waste, and abuse in the Medicaid Program.

Common functions of Program Integrity include prevention; investigation; education; audit; recovery of improper payments, cooperation with Medicaid Fraud Control Units (MFCU).

What is Fraud and Abuse?

Fraud: (per CFR 433.304 and 455.2)
An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other persons.  It includes any act that constitutes fraud under applicable Federal or State law.

Abuse: (per CFR 433.304 and 455.2)
Provider practices that are inconsistent with sound fiscal, business, or medical, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.  It also includes recipient practices that result in unnecessary cost to the Medicaid program.

False Claims Information

http://ag.ks.gov/fraud-abuse/false-claims

Terminated Provider List 

The Kansas Department of Health and Environment Division of Health Care Finance maintains a list of providers whose Medicaid provider agreement has been terminated.  Providers listed are not allowed to receive reimbursement for Medicaid services in any capacity. Refer to KAR 30-5-60 for the reasons a provider’s participation may be terminated.

Termination List (.pdf)

For inquires specific to the termination list contact Krista.Engel@ks.gov.

Visit the LEIE and SAM for a complete listing of those individuals excluded from receiving reimbursement for Medicaid services.  If an individual is on the LEIE or SAM they are not allowed to receive reimbursement for Medicaid services in any capacity even if they are not on this terminated provider list maintained by DHCF.

Resources

Code of Federal Regulations (CFRs) applicable to Program Integrity  (not an all inclusive list):

42 CFR 438 – Managed Care
42 CFR 455 – Program Integrity: Medicaid
42 CFR 456 – Utilization Control
42 CFR 1001 – Program Integrity – Medicare and State Health Care Programs
42 CFR 1002 – Program Integrity – State Initiated exclusions from Medicaid
42 CFR 1007 – State Medicaid Fraud Control Units

Office of Inspector General – List of Excluded Individuals/Entities (LEIE)
http://exclusions.oig.hhs.gov/

General Services Administration Excluded Parties List System (SAM)
https://www.sam.gov/

CMS Medicaid Integrity Program
http://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/index.html?redirect=/MedicaidIntegrityProgram/

CMS Medicaid Program Integrity Education
https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/edmic-landing.html

Attorney Generals Medicaid Fraud and Abuse Division
http://ag.ks.gov/fraud-abuse/medicaid-fraud

Exclusion Source: Kentucky Provider Terminated and Excluded Provider List

Format: Electronic
Update Schedule: Monthly

Description:

The Kentucky Department for Medicaid Services maintains a list of providers whose Medicaid provider agreement either have been terminated or who have been placed on an exclusion list.

An individual or entity terminated or excluded from participating in the Kentucky Medicaid program will not be reimbursed for services provided in any capacity or in any category under the Kentucky Medicaid program.

The termination or exclusion remains in effect until the provider is removed from this list. Where applicable and when determined, an end date is provided. Otherwise, a provider terminated by the Department for Medicaid Services may apply for reenrollment in the Kentucky Medicaid program if the provider meets the requirements of 907 KAR 1:671 and 907 KAR 1:672. It is the provider’s responsibility to notify Kentucky Medicaid if the circumstances which led to the termination and/or exclusion have changed.

Any provider participating or applying to participate in the Kentucky Medicaid program must search the list of excluded individuals and entities and the System for Award Management on a monthly basis to determine if any existing employee or contractor has been terminated or excluded from participation in the Kentucky Medicaid program or has been nationally excluded from Medicare or Medicaid. Also, any provider participating or applying to participate in the Kentucky Medicaid program must search all lists prior to hiring staff to ensure that any potential employee or contractor has not been terminated and/or excluded from participating in the Medicare or Medicaid program.

Please note that the Kentucky Medicaid Program only lists providers terminated or excluded from Kentucky’s Medicaid program. HHS/OIG excluded individuals and entities are not allowed to receive reimbursement for providing Kentucky Medicaid services in any capacity, even if they are not on the Kentucky Medicaid list.

Provider List

On Jan. 16, 2009, the Centers for Medicare and Medicaid Services issued a letter to state Medicaid directors repeating a long standing policy and clarifying federal statutory and regulatory prohibitions regarding providers from participation in federal health care programs. For more information please review the following letters.

Exclusion Source: 

Louisiana State Department of Health Adverse Actions List

Format: Electronic
Update Schedule: Monthly

Description: 

Single Person or Entity Search

This is a database containing all individuals and providers who are sanctioned, which may include exclusions, for-cause terminations, or disbarment through LDH Health Standards. You can search by name and verify with a Social Security Number (SSN) if you have one. If you have any questions or comments or if you need any for further assistance or information, please contact the Program Integrity Compliance Section at DHH.Medicaid.State.Exclusions@LA.gov.

Any person or entity is prohibited from participation in Medicaid if excluded, to include: employment directly or indirectly, contracting, or ownership. Doing so while excluded is violation and is considered a crime under LA R.S. 14:126.3.1 (2009). Although the stated period of time for the exclusion may have passed, this does not imply reinstatement. After the exclusion period has ended the excluded party may submit a written application for reinstatement. Resumption of participation in the Medicaid Program following exclusion is neither automatic nor a right. Applications for reinstatement will be reviewed by the state and given fair and impartial consideration. La.-R.S. 46:437.13 (C) (2008).

Providers that are terminated for cause are prohibited from participation for a minimum of 90 of days from the effective date. Once the minimum period has elapsed, the provider must re-enroll. Resumption of participation in the Medicaid Program following a termination for cause is neither automatic nor a right.

Employers must use the DSW registry to determine if there is a finding that a prospective hire has abused or neglected an individual being supported, or misappropriated the individual’s property or funds. If there is such a finding on the registry, the prospective employee shall not be hired.

The provider shall check the registry every six months to determine if any currently employed direct service worker or trainee has been placed on the registry with a finding that he/she has abused or neglected an individual being supported or misappropriated the individual’s property or funds.

Exclusion Source: MaineCare Services Provider Exclusion Report

Format: Electronic
Update Schedule: Monthly

Exclusion Source: Maryland Medicaid Sanctioned Providers List 

Format: Electronic
Update Schedule: Monthly

Exclusion Source: Massachusetts List of Suspended and Excluded Providers

Format: Electronic
Update Schedule: Monthly

Description:

Some providers may be suspended or excluded from working with MassHealth.

The MassHealth program maintains a list of providers who have been suspended or excluded from participating in the MassHealth program. This list is updated monthly and reflects suspensions or exclusions effective on or after March 23, 2010. They are listed according to the provider type at the time of such action.

Reasons for suspension or exclusion

Providers may be suspended or excluded due to

  • Not complying with participatory requirements of the MassHealth program
  • Being excluded under Medicare
  • Suspension of exclusion by any other state Medicaid agency
  • An inactive, terminated, suspended, or revoked license or authorization to provide services
  • Conviction of health care fraud
  • Pleading guilty to or being convicted of criminal activity materially related to Medicare or Medicaid
  • The U.S. Department of Health and Human Services initiating an action that is binding on a provider’s participation in the Medicaid program

If the period of suspension or exclusion expires, reinstatement rights into the MassHealth Program are not automatic. The individual or entity must submit an application for re-enrollment and cannot submit claims for services rendered to MassHealth members until they are notified that the application has been approved. Once approved, the provider’s name will be removed from the published list of suspended and excluded providers.

List of Suspended and Excluded Providers

MassHealth updates the list of suspended or excluded providers on a monthly basis. The update is posted around the second week of the month for the previous month.

Entities participating or applying to participate in MassHealth

On a monthly basis, any entity participating or applying to participate in the MassHealth program must search the list on this page, as well as the list of excluded individuals and entities (LEIE) of the federal Office of Inspector General to determine if any existing employee, contractor, owner, or board member has been suspended or excluded from participation in the Medicaid program.

In addition, the provider must immediately report any discovered exclusion of an employee or contractor to the Executive Office of Health and Human Services Compliance Office.

Exclusion Source: Michigan List of Sanctioned Providers

Format: Electronic
Update Schedule: Monthly

Description: 

List of Sanctioned Providers

Pursuant to Section 1128 and Section 1902(a)(39) of the Social Security Act, the Medicaid Program will not reimburse a provider for any services or items that were rendered or ordered/prescribed by a sanctioned (e.g., suspended, excluded) provider.  The effect of the provider’s sanction precludes them from furnishing, ordering, or prescribing services or items to any Medicaid beneficiary.  Claims for services/items rendered/ordered/prescribed by a sanctioned provider with dates of service or dispensing after the effective date of the sanction, will be rejected or disallowed if discovered during a post-payment review.  Refills of prescriptions written by a sanctioned provider must not be dispensed beyond the effective date of the sanction letter.  Claims for services/items rendered/ordered/prescribed by a provider for whom sanctions have been removed will be honored retroactively to the date the sanction ended.

 

Sanctioned Provider List

The MDHHS Sanctioned Provider List reflects the sanctioned provider’s name, NPI (if available), license/certification number if applicable), along with the sanctioning authority, sanction date and reason for sanction*. As additions and deletions are made to the list, the changes will be published in the listing below.  MDHHS does not publish paper copies of the complete listing.

When the sanctioning body enddates a provider’s sanction, that provider is removed from the MDHHS Sanctioned Provider List, but is not automatically reenrolled with MDHHS.  Provider’s wishing to reenroll with MDHHS must complete a new application process.

Supplemental Sanctioned Information

MDHHS makes every effort to publish sanction information related to its enrolled providers.  However, since this information often comes from sources outside of MDHHS, there may be instances of providers not appearing on the list. In addition, some providers (e.g., Adult Foster Care) are not currently enrolled with MDHHS although they provide services for Medicaid beneficiaries.  For that reason, the following sources should also be monitored to assure services are not provided by a sanctioned individual or entity.

*Definitions of HHS sanctions are available at www.ssa.gov/OP_Home/ssact/title11/1100.htm

Exclusion Source: Minnesota MHCP Excluded Providers List

Format: Electronic
Update Schedule: Monthly

Description: 

Excluded Provider Lists

Posted: 07-20-2017

The federal Health and Human Services–Office of Inspector General (OIG) has the authority to exclude individuals and entities from participation in Medicare, Medicaid and other federal health care programs. MHCP also excludes individuals and entities from participation in MHCP if they are on either the federal or state excluded provider list.

Follow these links to access the lists:

Also see MHCP Provider Screening Requirements.

Federal Exclusions List
Minnesota Excluded Providers

Checking Exclusion Lists

Reporting

MHCP Recovery of Funds Paid to Excluded Providers

Removal from Lists

Federal Exclusions List

The Office of Inspector General (OIG) provides information to the health care industry, patients and the public about individuals and entities who are currently excluded from participation in Medicare, Medicaid and all other federal health care programs. The OIG publishes a list of excluded providers and may impose civil monetary penalties against providers who employ or enter into contracts with excluded individuals or entities to provide services or items to MHCP members.

Providers who choose to enroll with MHCP must check all owners, managing employees, board members, employees or anyone else who works for the provider in any capacity against the Office of Inspector General exclusions database. The exclusions database provides information to the health care industry, patients and the public about individuals and entities currently excluded.

When an individual or entity is excluded, no payment will be made by any federal health care program for any items or services furnished, ordered or prescribed by the excluded individual or entity. This payment withholding applies to the excluded person and anyone who employs or contracts with the excluded person. The exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person.

Minnesota Excluded Providers

MHCP maintains and publishes lists of all individual or group providers suspended or terminated from receiving payment from Medicaid funds who MHCP has excluded. These lists are in addition to the federal exclusions list.

Besides checking the LEIE, you should also check the Minnesota excluded provider lists when you employ or enter into contracts with individuals or entities to provide services or items to MHCP members to ensure you allow only those who are qualified provide services and receive reimbursement. Anyone who is on the list is excluded from employment with an entity to provide services to members for whom you will submit claims to MHCP for reimbursement to. MHCP will deny claims for services or items rendered, ordered, referred or prescribed by excluded providers.

Owner information is not included on the individual provider list unless the owner is also enrolled as an individual provider of services.

For individual providers, the list shows the following:

  • • Provider type description
  • • Last name, first name, middle name
  • • Effective date of exclusion
  • • Address line 1 (This is the last known practice, organization or provider where the person was working)
  • • Address line 2
  • • City
  • • State
  • • ZIP code

For group or organization providers, the list shows:

  • • Provider type description
  • • Agency name
  • • Effective date of exclusion
  • • Address line 1
  • • Address line 2
  • • City
  • • State
  • • ZIP code

MHCP updates excluded provider lists monthly.

Checking the exclusion lists

As enrolling or enrolled MHCP providers, you must make sure you, your company, owners, managers, employees and contractors are not on an excluded provider list. Search List of Excluded Individuals/Entities LEIE and the Minnesota excluded group and individual providers lists by the individual’s or entity’s name:

  • • Before hiring or entering into contracts with individuals or entities to provide services or items to MHCP members.
  • • Ongoing (at least monthly) to check for changes since your last search.

Keep verifications for your own records of anyone on an exclusion list.

Verifying information

To verify information that may not be clear on the list, such as a person with a similar name, or a person with the same name but the list shows as a different provider type, call the MHCP Provider Call Center at 651-431-2700 or 800-366-5411. The call center representative will request identifying data, including but not limited to the tax ID number (EIN or FEIN), Social Security number (SSN) or date of birth. MHCP uses this information to confirm whether the person you are calling about matches the person displayed on the excluded providers list. The call center representative will only verify whether the information you provide matches the identifying information.

Reporting

Report any new exclusions you find in your search to MHCP Provider Enrollment. Fax information, including a cover sheet, to 651-431-7462. MHCP will also verify the entity and individuals listed against the LEIE on an ongoing basis to identify and remove anyone added to the federal list of exclusions.

Placement on an exclusion list

Providers named on the excluded providers list have been terminated due to fraud, theft, abuse, error or noncompliance in connection with a Minnesota health care program. Providers are notified that they are being terminated before they are named on the published list. They are not eligible for payment from MHCP effective the date of the notification. Excluded providers are not prohibited from providing services for private-pay clients.

MHCP recovery of funds paid to excluded providers

MHCP will not pay for services that providers or individual staff members provide to MHCP recipients after they have been terminated. If MHCP has already paid for services and then finds that a provider on an exclusion list performed the service, we may recover all funds paid.

Removal from lists

Individuals and entities who have been reinstated will no longer be on the OIG list.

A provider who is on the MHCP list must go to the Surveillance and Integrity Review Section (SIRS) to request removal from the list. This information is in the letter sent from SIRS when the provider was first added to the list. SIRS will notify MHCP provider enrollment directly when a determination is made to remove an entity from either of the MHCP exclusion lists.

Exclusion Source: Mississippi Sanctioned Provider List

Format: Electronic
Update Schedule: Monthly

Description: 

Provider Terminations

The Mississippi Division of Medicaid maintains a list of providers whose Medicaid provider agreement has been terminated. Refer to the Miss. Code Ann. §43-13-121 and the Code of Federal Regulations (CFR) §455.416 for the reasons a provider’s enrollment may be denied or revoked. The following list contains individuals or entities whose participation in the Medicaid program has been terminated for cause. Excluded individuals and entities are not allowed to receive reimbursement for providing Medicare and Medicaid services in any capacity, even if they are not on this listing.

The Affordable Care Act (ACA) requires that all physicians or other professionals who order or refer services for which a claim will be submitted to the Medicaid program must be enrolled as participating providers (see 42 CFR §455.410 (b)). Therefore, any un-enrolled provider, including any provider who is terminated from the Medicaid program for any reason, is not allowed to furnish, order, prescribe, or make referrals for services for which claims to the Medicaid program will be generated. Use of this list will help providers avoid submitting claims for medical care, services, and/or supplies that are ordered or prescribed by individuals or entities who are not authorized to submit such orders. Providers are responsible for screening all employees and contractors to identify excluded individuals and are responsible for searching the Office of Inspector General website, the System for Award Management (SAM) and the Mississippi Medicaid Sanction Provider List monthly to capture exclusions and reinstatements.

The Office of the Inspector General maintains a national list of all individuals who are excluded from receiving reimbursement from Medicare and Medicaid. For a comprehensive list of all individuals, go to https://exclusions.oig.hhs.gov/.

The files below contain providers who have been terminated from participation in the Mississippi Medicaid Program.

Exclusion Source: Missouri MMAC List of Terminated Individuals or Entities

Format: Electronic
Update Schedule: Monthly

Description: 

Provider Sanctions 

In the event a provider is deemed to be in violation of a provider manual, state statute, state regulation or federal regulation, MMAC is responsible for imposing a sanction on the provider. In determining the appropriate sanction MMAC takes into account the following aggravating and/or mitigating circumstances in accordance with 13 CSR 70-3.030.

The specific sanction imposed can be any of the following:

  • Education
  • Overpayment
  • Prepayment Review
  • Payment Suspension
  • Suspension
  • Termination

Learn more about Missouri Medicaid Program Regulations

Medicaid Terminations

The Missouri Medicaid program wants to ensure that the best medical professionals participate in the Medicaid program. When the program finds good reason that a provider should no longer be eligible to participate, they are placed on a list of terminated providers. To access this list, click on the link below, and read the disclaimer regarding the list of terminations.
List of Terminations:

  • View – A complete list of providers who have had their enrollment in the Missouri Medicaid program terminated since 2/3/2011 and the reasons for the termination.  Please note that not all providers who have had their enrollment terminated since 2/3/2011 are on the list.  The Missouri Medicaid Audit and Compliance Unit, rather, terminated the providers on the list for conduct which was deemed potentially detrimental to the Missouri Medicaid program. This list is reviewed monthly for updates.

Additional Resources for Provider Information:

  1. Health and Human Services. This Web site, hosted by the Office of the Inspector General within the federal Department of Health and Human Services (HHS), outlines their exclusion program and includes a searchable version of their List of Excluded Individuals/Entities (LEIE).
  2. Government Services Administration. This Web site is provided as a public service by the Government Services Administration for the purpose of efficiently and conveniently disseminating information on parties that are excluded from receiving federal contracts, certain subcontracts, and certain federal financial and non-financial assistance and benefits, called the System for Award Management (SAM).

Information About Terminated Individuals or Entities

This Web site contains lists of individuals or entities whose participation in the Missouri Medicaid program has been terminated under the provisions of  13 CSR 70-3.030 .

Using the Lists of Terminated Individuals or Entities

The Affordable Care Act (ACA) requires that all physicians or other professionals who order or refer services for which a claim will be submitted to the Medicaid program must be enrolled as participating providers (see 42 CFR 455.410 (b)). Therefore, any un-enrolled provider, including any provider who is terminated from the Medicaid program for any reason, is not allowed to furnish, order, prescribe, or make referrals for services for which claims to the Medicaid program will be generated.

Use of this list will help providers avoid submitting claims for medical care, services, and/or supplies that are ordered or prescribed by individuals or entities who are not authorized to submit such orders. Enrolled providers should verify that the orderer has not been terminated before filling an order or prescription. If the orderer’s or prescriber’s name appears on the List of Terminated Individuals or Entities, Medicaid should not be billed for the care, services, or supplies ordered, prescribed, or provided by that person or entity.

Any claim submitted for medical care, services, or supplies ordered/prescribed by any providers appearing on the List of Terminated Individuals or Entities may be denied, and the enrolled provider dispensing prescriptions or filling orders may be held responsible for repayment of any payments made by the Medicaid program under these circumstances.

For orders or prescriptions requiring prior approval or prior authorization, it should be noted that the receipt of an approval or authorization is not a guarantee of payment. Payment is subject to a patient’s eligibility and compliance with all applicable statutes and policies.

Providers are reminded that part of an effective compliance program should include checking the sanction list at least on a monthly basis. This will make providers aware of any terminations that may have taken place since the last search.

Any provider who has been terminated on or after January 1, 2011 from Medicare or from the Medicaid program or CHIP of any other state may not be enrolled or reinstated in the Missouri Medicaid program (42 CFR 455.416 (c)).

Exclusion Source: Montana Excluded or Terminated Montana Medicaid Providers

Format: Electronic
Update Schedule: Monthly

Description: 

Excluded or Terminated Montana Medicaid Providers

When determined by the appropriate authority, that a Montana Medicaid Provider needs to be terminated or excluded from the Medicaid program under 42 CFR 1002.210, the state agency must provide notification. In accordance with Administrative Rules of Montana (ARM) 37.85.507, 42 CFR 1001.2005 and 42 CFR 1001.2006 this web site serves as notice to the state licensing agencies and others regarding these excluded and or terminated providers.

The following list is not all-inclusive for all excluded or terminated providers and should not be used solely to determine or verify a provider’s enrollment status or ability to provider services under the Montana Medicaid program.

Please check the following web sites to determine provider status:

Exclusion Source: Nevada Medicaid Sanctions and Exclusions List 

Format: Electronic
Update Schedule: Monthly

Description:

PROVIDER EXCLUSIONS, SANCTIONS AND PRESS RELEASES

These providers have been excluded/sanctioned from the Nevada Medicaid Program. Reinstatement of excluded entities and individuals is not automatic. Those providers who were excluded by the Office of Inspector General (OIG) and wish to participate again in the Medicaid Program, must provide documentation from the OIG that they have been reinstated. There are no provisions for early or retroactive reinstatement. For more information on reinstatement, visit the U.S. Department of Health and Human Services, OIG website for Applying for ReinstatementList is updated periodically.

Effective 8/1/2017 all column titles have been updated to separate Nevada Medicaid Sanctions and Office of the Inspector General Exclusions. Previous information has not been affected. Last updated on 9/4/2020.

To determine if an individual or Health Care Entity is excluded from participation in Medicare and Medicaid on a nation-wide basis, see the Office of Inspector General’s Website, List of Excluded individuals/Entities (LEIE).

Exclusion Source: New Hampshire Medicaid Provider Exclusion and Sanction List

Format: Electronic
Update Schedule: Monthly

Description: 

NH Medicaid Provider Exclusion and Sanction List
The New Hampshire Medicaid program wants to ensure that the best medical professionals participate in the Medicaid program. When the program finds good reason that a provider should no longer be eligible to participate, they are placed on a list of terminated providers. To access this list, click on the link below, and read the disclaimer regarding the list of terminations.

List of Terminations Microsoft Excel Symbol (updated 07/14/2020)
A complete list of providers who have had their enrollment in the New Hampshire Medicaid program terminated since 4/01/2013 and the reasons for the termination. Please note that not all providers who have had their enrollment terminated since 4/01/2013 are on the list. The New Hampshire Medicaid Program Integrity Unit, rather, terminated the providers on the list for conduct which was deemed potentially detrimental to the New Hampshire Medicaid program. This list is reviewed monthly for updates.

Medicaid providers are reminded that utilizing this list does not replace the requirement to complete the following database searches:

Exclusion Source: New Jersey Medicaid Fraud Division Debarment List

Format: Electronic
Update Schedule: Monthly

Description: 

Disqualified Providers

A disqualified provider is a person or an organization that has been excluded from participation in federal or State funded health care programs including but not limited to Medicare or Medicaid. Any products or services that a disqualified provider furnishes, orders or prescribes are not eligible for payment under those programs. This payment prohibition extends to anyone who employs or contracts with the disqualified provider, as well as to any facility where the disqualified provider delivers services that might otherwise be reimbursable.

The links on this page will help providers determine whether the individuals they employ or contract with are excluded from the New Jersey Medicaid program. In addition, they provide information on individuals holding professional licenses in the State of New Jersey.

State of New Jersey Debarment List

The State of New Jersey Medicaid Fraud Division is responsible for the oversight and maintenance of the NJ Debarment List (medical code).  All updates will be done at the end of each month.  If you are responsible for verifying a provider, please refer to the list below.  If you find a potential match, of a prospective employee, please complete the Exclusions Verification Form and return via email to: MFDVerifyMailbox@osc.nj.gov.  Upon completion you will receive an auto reply with the next steps in the process.  Any additional inquiries regarding an Exclusionary Action can also be made via the verify mailbox.

Click here for: State of New Jersey Medicaid Fraud Division Debarment List

*Any non-medical inquiry will not be processed or responded to, please contact the appropriate agency for such inquiries.

Links for OIG Verification andNeighboring States

General Information on New Jersey Licensed Medical Professionals

Exclusion Source: No Available Medicaid Exclusion List

Format: N/A
Update Schedule: N/A

Description: 

Visit the New Mexico Office of Inspector General site to learn more.

The mission of the Office of the Inspector General (OIG) is to prevent and detect fraud, waste and abuse in the New Mexico Human Services Department’s (HSD’s) public assistance programs and services, and internal operations. The OIG conducts financial and program audits, criminal, civil, and administrative investigations, special reviews, and administers the Medicaid Program Integrity Unit and Public Assistance Reporting Information System (PARIS) programs.  The OIG is comprised of the Internal Review Bureau, Investigations Bureau, and Central Office.

Exclusion Source: NYS Medicaid Exclusion List

Format: Electronic
Update Schedule: Monthly

Description: 

INFORMATION ABOUT EXCLUDED INDIVIDUALS OR ENTITIES

The NYS Medicaid Exclusion List identifies individuals or entities who have been excluded from participating in the NYS Medicaid program under the provisions of 18 NYCRR § 515.3 and/or 18 NYCRR § 515.7.

An excluded individual or entity cannot be involved in any activity relating to furnishing medical care, services, or supplies to recipients of medical assistance for which claims are submitted to the program, or relating to claiming or receiving payment for medical care, services or supplies during the period of exclusion. See 18 NYCRR § 515.5 for more information regarding the effect of exclusion.

USING THE NYS MEDICAID EXCLUSION LIST

Unless otherwise required by law or contract, it is recommended that providers check the NYS Medicaid Exclusion List at least every 30 days as a best practice.

Use of this list will help providers avoid submitting claims for medical care, services, and/or supplies that are ordered or prescribed by individuals or entities who are not authorized to submit such orders. Enrolled providers should verify that the orderer has not been excluded before filling an order or prescription. If the orderer’s or prescriber’s name appears on the NYS Medicaid Exclusion List, Medicaid should not be billed for the care, services, or supplies ordered, prescribed, or provided by that person or entity.

Any claim submitted for medical care, services, or supplies ordered/prescribed by any individuals or entities appearing on the NYS Medicaid Exclusion List may be denied, and the enrolled provider dispensing prescriptions or filling orders may be held responsible for repayment of any payments made by the Medicaid program under these circumstances.

For orders or prescriptions requiring prior approval or prior authorization, it should be noted that the receipt of an approval or authorization is not a guarantee of payment. Payment is subject to a patient’s eligibility and compliance with all applicable statutes and policies.

MEDICAID EXCLUSIONS 

Medicaid seeks to ensure that the medical providers participating in the program are professional, ethical, and provide recipients with quality healthcare services. When it is determined that a provider should no longer be eligible to participate in the program due to their unethical behavior, the individual or the entity is placed on a list of excluded providers.

To access this list, click on the links below. View explanation and disclaimers regarding the NYS Medicaid Exclusion List.

Providers with questions about exclusions should call the New York State Office of the Medicaid Inspector General (OMIG) at 518-402-1816.

Should you have a question regarding this notice or the status of the providers contained on the exclusion list, please contact the OMIG Administrative Remedies Unit at (518) 402-1816. If you would like additional information about the exclusion of any Medicaid provider, please submit a Freedom of Information Law (FOIL) request.

LIST OF EXCLUSIONS:
ADDITIONAL RESOURCES FOR INFORMATION ON PROVIDERS
  • Enrolled Provider Search. Individuals who order/prescribe/refer/attend services payable by the fee-for-service Medicaid program must be enrolled. Billing and rendering providers should use this search feature to confirm the individual is enrolled.
  • Professional Discipline. This website contains summary information of disciplinary actions taken against licensees by the Board of Regents in New York State since January 1, 1994.
  • Professional Misconduct and Physician Discipline. This website offers a search capability for public documents regarding Professional Misconduct and Physician Discipline actions taken since 1990 for physicians, physician assistants, and specialist assistants.
  • Health and Human Services. This website is the exclusions database for the federal Office of the Inspector General within the Department of Health and Human Services (HHS).
  • State Education License Search. This website contains searchable information regarding professional individuals, establishments and entities which have been granted licenses or permits by the New York State Department of Education Office of Professions.
  • Physician Profiles. This website provides profiles on all licensed doctors of medicine and doctors of osteopathy registered to practice in New York State.
  • System for Award Management. This website provides information on parties excluded from receiving federal contracts.

Exclusion Source: North Carolina Medicaid Provider Termination and Exclusion List

Format: Electronic
Update Schedule: Monthly

Description: 

Excluded Providers

An excluded provider is an individual or entity that cannot bill or cause services to be billed to Medicare, Medicaid or NC Health Choice. DHHS works diligently to prevent excluded providers from participating in NC Medicaid and NC Health Choice to comply with federal regulations.

The North Carolina Medicaid Provider Termination and Exclusion list is updated monthly. The termination or exclusion is in effect until the provider is removed from this list.

The U.S. Department of Health and Human Services Office of the Inspector General maintains a national list of all individuals excluded from receiving Medicare and Medicaid reimbursement.

National List

Exclusion Source: North Dakota Provider Exclusion List

Format: Electronic
Update Schedule: Monthly

Description: 

Medical Services – Fraud & Abuse

The North Dakota Department of Human Services’ mission is to provide quality, efficient, and effective human services, which improve the lives of people.

Medicaid and the Children’s Health Insurance Program (CHIP) provides healthcare coverage to qualifying low-income, disabled individuals and children, and families. Fraud can be committed by Medicaid providers or recipients. The Department does not tolerate misspent or wasted resources.

By enforcing fraud and abuse efforts:

  • Medicaid providers receive the best possible rates for the services they provide to Medicaid & CHIP recipients;
  • Medicaid & CHIP recipients are assured that their out-of-pocket costs are as low as possible;
  • Tax dollars are properly spent;
  • North Dakota Medicaid & CHIP recipients receive necessary healthcare services.

If a provider on the ND Medicaid Provider Exclusion list is a Qualified Services Provider (QSP), they will not have an National Provider ID number. North Dakota can verify QSP providers by name, date of birth, and last four of their social security number. Send all inquiries to ND Medicaid.

ND Medicaid Provider Exclusion List
 – Includes Qualified Service Providers (August 2020) PDF
ND Medicaid Provider Exclusion List – Includes Qualified Service Providers (August 2020) Excel

Searchable National Provider ID Registry


What is Fraud? Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to them or some other person.

What is Abuse? Abuse is when provider practices are inconsistent with sound fiscal, business, or medical practices that result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or services that fail to meet professionally recognized standards for healthcare. Abuse may also include recipient practices that result in unnecessary costs to the Medicaid and CHIP programs.


What are the types of fraud or abuse?

Provider: committed by practitioner, health facility, or other entity that provides services to Medicaid recipients.

Examples:

  • Billing for services not performed
  • Billing for a more expensive service than was actually rendered
  • Billing twice for the same service(s)
  • Billing for services that should be combined into one billing (unbundling)

Recipient: committed by a Medicaid or CHIP recipient

Examples:

  • Providing false information to obtain Medicaid or CHIP eligibility
  • Paying cash for some services (prescriptions) to bypass refill edits
  • A recipient may lend someone their Medicaid card so the individual can obtain unauthorized medical services.

Exclusion Source: Ohio Medicaid Provider Exclusion and Suspension List

Format: Electronic
Update Schedule: Monthly

Description: 

Ohio Medicaid Provider Exclusion and Suspension List

The Ohio Department of Medicaid (ODM) maintains a list of providers who have been excluded or that are currently suspended from the Ohio Medicaid program. This list will be updated frequently. Please be sure you have the most up-to-date information by using the file available on this page, instead of storing one on your computer system. In order to assist with identification, the provider’s last known address and date of birth are included. Please note: that this list does not include the names of individuals who have been terminated from the Ohio Medicaid program due to license issues.

Ohio Medicaid Provider Exclusion Suspension List (Updated 8/28/2020)

If an individual or company is on the list, the individual or company may not be an owner in whole or in part; officer or partner; authorized agent, associate, manager, or employee of a Medicaid provider. The individual or company is prohibited from owning, contracting for, arranging for rendering or ordering services for Medicaid recipients or receiving direct or indirect reimbursement of Medicaid funds in the form of salary, shared fees, contracts, kickbacks, or rebates from or through any participating provider or risk contractor.

Medicaid providers are reminded that utilizing this list does not replace the requirement to complete the following database searches:

For questions regarding exclusions and suspensions from the Ohio Medicaid program, send an email to “Exclusions” in the subject line and include the individual’s full name (including middle initial) and the last four digits of their Social Security number to: exclusions@medicaid.ohio.gov.

Exclusion Source: No Available Exclusion List

Format: N/A
Update Schedule: N/A

Description: 

Visit the Oklahoma Department of Health site to learn more about excluded individuals and entities.

Exclusion Source: No Available Exclusion List

Format: N/A
Update Schedule: N/A

Description: 

Visit the Oregon DOJ Consumer Protection site to learn more about Medicaid Fraud.

Exclusion Source: Medicheck (Precluded Providers) List

Format: Electronic
Update Schedule: Monthly

Medicheck List (Precluded Providers)

What is the Medicheck List?

The Medicheck List identifies providers, individuals, and other entities who are precluded from participation in the Medical Assistance (MA) Program. This list was previously sent monthly by way of an 88 series MA Bulletin. Effective January 2002, hard copies of the list were discontinued and all listings and updates are now issued through this site. Previous versions of the Medicheck List Bulletins can be viewed from the Medical Assistance Bulletins page on this site. The Medicheck List can be searched by provider name, license number, business name, or by using the “Search by” pull-down menu; also available is a complete Medicheck list, sorted by provider last name. The Medicheck List website is updated daily.

Medicheck FAQ

Why is it necessary for MA providers (both in the fee-for-service and managed care delivery systems) to use the Medicheck List?
It is necessary for providers to examine the Medicheck list to assure that an order for a service or a prescription is not initiated by individuals who are no longer permitted to participate in the MA Program. Under applicable law, the department and managed care organizations will not pay for any services prescribed, ordered, or rendered by the providers or individuals listed on the Medicheck List, including services performed in an inpatient hospital or long-term care setting. See 55 Pa. Code Sections 1101.42(c) and 1101.77(c).

In addition, subsequent to the effective date of the termination or preclusion, any entity of which five percent (5%) or more is owned by a sanctioned provider or individual will not be reimbursed for any items or services rendered to MA recipients.

It is your responsibility to utilize this online searchable listing to screen all employees and contractors (both individuals and entities) at the time of hire or contracting; and, thereafter, on an ongoing monthly basis to determine if they have been excluded from participation in the state and federal health care programs.

What is the LEIE database, and why should providers use it in addition to the Medicheck List?
The List of Excluded Individuals/Entities (LEIE), maintained by the Department of Health and Human Services, Office of Inspector General (DHHS/OIG), is a database of all individuals or entities that have been excluded nationwide from participation in any federal health care program, e.g., Medicaid and Medicare. Pursuant to federal and state law, any individual or entity included on the LEIE is ineligible to participate, either directly or indirectly, in the MA Program. The LEIE is easy to use and can be searched and downloaded from the OIG’s web site at http://oig.hhs.gov/fraud/exclusions.asp. Although the Department makes best efforts to include on the Medicheck List all federally excluded individuals/entities who practice in Pennsylvania, providers should also use the LEIE to ensure that the individual/entity is eligible to participate in the MA Program.

Are providers automatically reinstated in the Medical Assistance Program at the end of a preclusion period?
No. In accordance with 55 Pa. Code Section 1101.82(a), providers who have reached the end of their preclusion period must request and be re-enrolled by the Department in order to participate.

How can a potential match be confirmed?
All sanction information history is now displayed on the Medicheck list. Please verify the end date before any further inquiries are made. If there is an end date listed that has already passed, the individual or entity is no longer excluded effective the end date and a confirmation is NOT required. If, after searching the Medicheck list, you discover a potential match on an individual or entity, the Bureau of Program Integrity (the Bureau) can assist you in validating that match. Please note that the Bureau does not perform routine screenings for providers or contracted agencies hired to perform such screenings.

In order to validate a potential match, the Bureau requests that you provide the following information via email @ RA-BPI-Preclusions@pa.gov:

      • Name of the individual or entity (as it is listed on the Medicheck list)
      • Date of Birth
      • Last four digits of the potential match’s Social Security number
      • License number of the potential match (if applicable)

Please send only one (1) email per individual or entity that you are researching as we compare the name you provide to all potential matches.

Please do NOT send multiple requests within the same email.

Please allow ten (10) business days from the Department’s receipt of the request to receive a response.

The Medicheck search allows individuals to download a file of all precluded individuals. View instructions on importing this file into Microsoft Access.

Exclusion Source: South Carolina Excluded Providers List 

Format: Electronic
Update Schedule: Monthly

Exclusion Source: No Available Exclusion List

Format: N/A
Update Schedule: N/A

Description:

South Dakota Medicaid excluded providers can be found on the U.S. Department of Health & Human Services Office of Inspector General’s Exclusions Database.

Exclusion Source: Tennessee Terminated Provider List

Format: Electronic
Update Schedule: Monthly

 

Exclusion Source: List of Excluded Individuals/Entities by Texas OIG 

Format: Electronic
Update Schedule: Monthly

Description: 

About the Texas Exclusions Database

The Office of Inspector General works to protect the health and welfare of people receiving Medicaid and other state benefits. To help protect these recipients, OIG may prevent certain people or businesses from participating as service providers. The people or businesses who are excluded from participating as providers are added to the Texas Exclusions List.

A person, or entity, may be excluded for many reasons. These include, but are not limited to:

Every service provider is responsible for making sure that no excluded individuals or entities are receiving state funds. Specifically, it is each provider’s or person’s responsibility to ensure that items or services furnished personally by, at the medical direction of, or on the prescription or order of an excluded person are not billed to the Titles V (Maternal and Child Health Services), XIX (Medicaid), XX (Block Grants for Social Services), and/or other HHS programs after the effective date of exclusion. This section applies regardless of whether an excluded person has obtained a program provider number or equivalent, either as an individual or as a member of a group, prior to being reinstated.

When a person or entity is excluded from Medicaid, Title V, Title XX, and other HHS programs,

  • The person or entity will not be reimbursed for any item or service they may furnish.
  • The person or entity may neither personally, nor through a clinic, group, corporation, or other means, bill or otherwise request or receive payment for any Title V, XIX, or XX, or other HHS programs, or request or receive payment from the Medicaid program.
  • The person or entity may not assess care, or order or prescribe services to Title V, XIX, or XX, or other HHS programs recipients. This applies regardless of whether the services were provided directly or indirectly. Also, a clinic, group, corporation, or other entity is not allowed to submit claims for any assessments, services, or items provided by a person who is excluded from participation.
  • Any entity that employs, or otherwise associates with, an excluded person is not allowed to include within a cost report, or any other documents used to determine an individual payment rate, a statewide payment rate or a fee, the salary, fringe benefits, overhead, or any other costs associated with the person excluded.
  • If a person who is later excluded has written an order or prescription before the exclusion date, the prescription remains valid for the duration of the order or prescription.
  • If, after a person or entity is excluded, they submit claims for payment, we may assess administrative damages and penalties.

All service providers should check OIG’s exclusion list monthly.

About Texas HHSC OIG Exclusion Program

The Texas Health & Human Services Commissions (Commission) Office of Inspector General (OIG) works diligently to protect the health and welfare of Texas Medicaid and other HHS programs beneficiaries by preventing the participation of certain individuals and businesses. The OIG excludes individuals and entities affected by various legal authorities. A listing of all currently excluded parties is maintained by OIG and is called the List of Excluded Individuals/Entities by Texas OIG.

Bases for exclusion include convictions for program-related fraud and patient abuse, licensing board actions, U.S. Health & Human Services OIG (Medicare) exclusion actions, and “Permissive” exclusions as allowed by various legal authorities.

It is each provider’s or person’s responsibility to ensure that items or services furnished personally by, at the medical direction of, or on the prescription or order of an excluded person are not billed to the Titles V (Maternal and Child Health Services), XIX (Medicaid), XX (Block Grants for Social Services), and/or other HHS programs after the effective date of exclusion. This section applies regardless of whether an excluded person has obtained a program provider number or equivalent, either as an individual or as a member of a group, prior to being reinstated.

The effect of exclusion2 from Medicaid, Title V, and Title XX and other HHS programs is as follows:

  • No payment will be made by these programs for any item or service furnished by the exclude person on or after the effective date of exclusion;
  • The excluded person must neither personally nor through a clinic, group, corporation, or other association or entity, bill or otherwise request or receive payment for any Title V, XIX, or XX, or other HHS programs for items or services provided on or after the effective date of the exclusion. Exclusion also prevents the excluded person from providing any services pursuant to the Medicaid program, whether or not you directly request Medicaid program payment for such services;
  • The excluded person must not assess care or order or prescribe services, directly or indirectly, to Title V, XIX, or XX, or other HHS programs recipients after the effective date of exclusion. A clinic, group, corporation, or other association or entity must not submit claims for any assessments, services or items provided by a person within such organization or entity who is excluded from participation, unless the services or supplies were provided before the effective date of exclusion;
  • An entity that employs or otherwise associates with a person excluded from participation in Titles V, XIX, or XX, other HHS programs must not include within a cost report or any documents used to determine an individual payment rate, a statewide payment rate or a fee, the salary, fringe benefits, overhead, or any other costs associated with the person excluded;
  • An order or prescription written before the exclusion effective date is valid for the duration of the order or prescription; and
  • An order or prescription written before the exclusion effective date is valid for the duration of the order or prescription; and
  • If, after the effective date of an exclusion, claims are submitted or are cause to be submitted for services or items furnished within the period of exclusion, administrative damages and/or penalties may be imposed.3

1 See 1 Texas Administrative Code (TAC) §371.1677(a)
2 See 1 TAC §371.1673 “Scope and Effect of Exclusion”
3 See Social Security Act §§ 1128(a)(1)(D), 1128B(a)(3), 1 TAC §§ 371.1721-371.1741, and Texas Human Resources Code § 32.039

Contact Us About the Exclusion Program

Exclusion Source: No Available Exclusion List

Format: N/A
Update Schedule: N/A

Description: 

Visit the Utah Department of Health Medicaid Program site to learn more.

Exclusion Source: Vermont Medicaid Excluded Providers List

Format: Electronic
Update Schedule: Monthly

Description: 

Disclaimer

This list should not be considered comprehensive of all providers excluded from participation in the Vermont Medicaid program; action by other federal or state entities may also result in exclusion. The providers identified herein are those that have been excluded by the Vermont Department of Health Access and the Agency of Human Services. This list may or may not include providers excluded due to action taken by other federal or state entities. This list contains the names of providers whose participation with Vermont Medicaid was terminated “for cause”, which may include conduct deemed as potentially detrimental to the Vermont Medicaid program.

Consideration

  • If your name appears on the Excluded Providers List and your exclusion term has expired, you may complete a new application for consideration to participate with Vermont Medicaid. Information can be found at http://www.vtmedicaid.com/#/provEnrollDataMaint
  • If your name appears on the Excluded Providers List and your exclusion term has expired, you may request that your name be removed from the Excluded Providers List. Requests for removal of Provider name(s) from the Excluded Providers List should be submitted to the address below.
  • If you wish to have a reconsideration of DVHA’s decision to preclude you from participation with Vermont Medicaid your request must include documentation with compelling and extenuating circumstances. Reconsideration information can be sent to the address below.

Please submit re-consideration requests to

Member and Provider Services
Department of Vermont Health Access
280 State Drive, NOB 1 South
Waterbury, VT 05671-1010

Questions pertaining to exclusions can be sent to vtproviderenrollment@dxc.com

Affordable Care Act Requirements

The Affordable Care Act requires mandatory enrollment for all ordering physicians or other professionals who prescribe, order, or refer services to Medicaid or provide services under the State Plan or under a waiver of the plan (see 42 CFR 455.410(b)). Therefore, any non-enrolled provider, including any provider who is terminated from the Medicaid Program, for any “for cause” reason, is not permitted to provide services to Medicaid recipients. Medicaid providers and their agents are reminded that the Vermont Excluded Provider list is not all-inclusive. Additional information about provider exclusions is available but not necessarily limited to the information contained on the following websites:

Excluded Providers List

Please contact vtproviderenrollment@dxc.com for archived list(s) of Exclusions The most current list is below.

Exclusion Source: No Available Exclusion List

Format: N/A
Update Schedule: N/A

Description: 

Visit the Virginia Department of Medical Assistance Services Medicaid site to learn more.

Exclusion Source: Washington Provider Termination and Exclusion List

Format: Electronic
Update Schedule: Monthly

Description: 

Provider Termination and Exclusion List

The following lists contain:
  • Individuals or entities whose participation in the Medicaid program has been terminated for cause under the provision of WAC 182-502-0030 (HCA) or 388-71-0551; 388-71-0540; 388-71-0544; 388-110-260 (DSHS).
  • Medicaid providers who have been excluded from participation (see 42 CFR 1001).

Not every action taken by the Department of Social and Health Services (DSHS) or the Health Care Authority (HCA) involves a finding of wrongdoing (see WAC 182-502-0030(b)). Individuals terminated without cause pursuant to WAC 182-502-0040 are not included on this list.

The Affordable Care Act requires that all ordering physicians or other professionals who prescribe, order, or refer services to Medicaid or provide services under the State Plan or under a waiver of the plan to be enrolled as participating providers (see 42 CFR 455.410(b)).  Therefore, any non-enrolled provider, including any provider who is terminated from the Medicaid Program, for any reason, is not permitted to provide services to Medicaid recipients.

Exclusion Source: DC.gov Provider Sanctions List

Format: Electronic
Update Schedule: Monthly

Description: 

When a provider does not meet expectations or established DDS/DDA requirements, that provider, a particular service offered by that provider or service location of that provider may be added to the DDS/DDA Provider Sanctions List. This action prohibits DDA Service Coordinators from referring or transitioning new people to that provider, service or service location until they are removed from the list.

Exclusion Source: West Virginia Medicaid Provider Exclusions and Terminations 

Format: Electronic
Update Schedule: Monthly

 

Exclusion Source: No Available Exclusion List 

Format: N/A
Update Schedule: N/A

Description: 

Visit the Wisconsin Department of Health Services Office of Inspector General site to learn more.

Exclusion Source: Wyoming Excluded Providers

Format: Electronic
Update Schedule: Monthly

Smarter Exclusion Monitoring for Healthcare Organizations

The OIG is serious about enforcing fines and penalties and eliminating fraud, waste, and abuse from federal healthcare programs. If you are only conducting federal OIG LEIE screening, you should enhance your compliance program to include SAM.gov and the available state Medicaid exclusion lists.

Effective compliance programs require a monitoring and auditing function. Ensuring that exclusion monitoring is an integral part of your monthly monitoring helps mitigate your risk and keep you audit-ready. ProviderTrust helps give you the freedom from tedious processes to focus on people with smarter automated exclusions monitoring solutions.

If you have any questions regarding whether your compliance program is executing best practices in this area, our team is always available to discuss and advise!


Still have questions about exclusion monitoring?

Read more about OIG Exclusion Monitoring


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