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Fingerprint-Based Background Checks for Certain Providers Are Standard for Medicare Provider Enrollment


One of the enhanced provider enrollment screening provisions in Section 6401 of the Affordable Care Act (ACA) requires fingerprint-based background checks for certain providers and suppliers.

The Centers for Medicare & Medicaid Services (CMS) administers this screening for those providers and suppliers deemed in the “high” level risk category. The screening requirements apply to individuals with a 5% or greater ownership in a provider or supplier that falls into the high risk category including:

  • Suppliers of durable medical equipment, prosthetics, orthotics and supplies
  • Home health agencies
  • Other providers and suppliers who have been specifically designated as high risk.

This enhanced screening provision also applies to providers and suppliers who have been elevated to the high risk category. CMS has the ability to modify a provider or supplier’s screening level (in other words, move them from risk levels of “moderate” to “high” or from “limited” to “high”). Here are a few examples of situations in which CMS may make this adjustment:

  • CMS has imposed a suspension of payments within the last 10 years.
  • The provider or supplier has been excluded from Medicare by the OIG (Office of Inspector General).
  • CMS has revoked billing privileges within the last 10 years.
  • The provider or supplier has been excluded from any Federal Health Care program.
  • The provider or supplier has been terminated or is otherwise precluded from billing Medicare.

You can read the full CMS announcement of the implementation of fingerprint-based background checks in this MLN Matters release.

How the Fingerprint-Based Background Check Works

CMS has been notifying affected providers and suppliers of the requirement since 2014. Individual notices identify local fingerprint-based background check contractors. After receiving the notice, the relevant individuals have 30 days to submit the information. They must contact the fingerprint-based background check contractor in advance.

Affected providers must bear the cost of fingerprinting. These are preferred in electronic format from a fingerprint-based background check contractor. Paper FD-258 cards are also acceptable.

The FBI will compile background history based on the fingerprints within 24 hours of receipt and will share with the background check contractor. The CMS will make a final determination after reviewing the data and assessing the recommendation of the background check contractor.

Let Us Manage All Your Payer Enrollment Services

If you require medical credentialing and payer enrollment needs for your practice or medical facility, please contact 1st Assistant. Our experienced and dedicated specialists will provide all credentialing and enrollment services quickly and will monitor your account for ongoing updates and re-attestations. Heidi Henderson, our company owner and President, is eager to meet you and discuss your payer enrollment needs. Please call us at 512.201.2668 or contact us via the website.

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