All MO HealthNet providers are required to be screened during their initial enrollments and revalidations, according to their assigned risk category. For additional information for each risk category, review 13 CSR 65-2 and 42 CFR 455.450. The categories are defined by federal regulations based on the risk of fraud, waste, and abuse to the MO HealthNet Program. The three risk categories are limited, moderate, and high.
To determine which category is assigned to each provider type, review the Provider Risk Category Table below. Any provider who is not categorized by state and federal regulations within one of the risk categories shall be screened as a moderate risk provider per 13 CSR 65-2.020(10)(G). Additionally, per 13 CSR 65-2.020(10)(D) if a provider could fit within more than one screening level, the highest risk category of screening is applicable.
Per 13 CSR 65-2 and 42 CFR 424.518, the categorical risk may be adjusted when any of the following occurs:
- Missouri Medicaid Audit and Compliance (MMAC) imposes a payment suspension on a provider based on a credible allegation of fraud, waste, or abuse by the provider
- Provider has an existing Medicaid overpayment
- Provider has been excluded by the federal Department of Health and Human Services (DHHS), Office of the Inspector General or another state’s Medicaid program within the previous 10 years
The upward adjustment of the provider’s categorical risk level for a payment suspension or overpayment shall continue only so long as the payment suspension or overpayment continues or when both of the following occurs:
- MMAC or the Centers for Medicare & Medicaid Services (CMS) lifted a temporary moratorium for the provider type in the previous six (6) months
- Provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider at any time within six (6) months of the date the moratorium was lifted
Questions regarding assigned risk categories may be submitted by calling (833) 818-1183 or by email to MMAC.ProviderEnrollment@dss.mo.gov.
- Provider Risk Category Table
Provider Type Description
Provider Type Number
Assigned Risk Category
Acupuncture 72
Limited Adult Day Care 29
Moderate Aged & Disabled Waiver 28
Moderate Alcohol & Drug Rehabilitation 86
Limited Ambulance 80
Moderate Assistant Physician 21
Limited Audiologist 33
Limited Behavior Analyst 73
Limited Case Management 18
Moderate Certified Community Behavioral Health Clinic 88
Limited Certified Registered Nurse Anesthetists (CRNA) – Anesthesiologist Assistant (AA) Services 91
Limited Chiropractors 23
Limited Community Mental Health Center 56
Limited Dental Hygienist 74
Limited Dentist 40
Limited Development Disabilities (DD) Waiver 85
Moderate Diabetes Preventive Care 37
High Disease Management 35
Limited Durable Medical Equipment (DME) Supplier 62
High Electronic Health Record Incentives 19
Limited Free Standing Birth Center 61
Moderate Home Health Agency 58
High Hospice 82
Moderate Hospital 1
Limited Hospital Department 54
Limited Independent Clinic 50
Limited Independent Laboratory 70
Moderate Independent or Portable X-ray, Independent Diagnostic Testing Facility (IDTF) 71
Moderate Lead Environmental Assessment 39
Limited Managed Care - Part D 84
Moderate Managed Care Organization 81
Moderate Mental Hospital 2
Limited Non-Emergency Medical Trans (NEMT) 65
Moderate Nurse Midwife 25
Limited Nurse Practitioner 42
Limited Nursing Home 10
Limited Occupational Therapist 47
Limited Optician 32
Limited Optometrist 31
Limited Personal Care 26
Moderate Pharmacy 60
Limited Physical Therapist 48
Moderate Physician - DO 24
Limited Physician - MD 20
Limited Physician Assistants 22
Limited Planned Parenthood Clinic 52
Limited Podiatrist 30
Limited Private Duty Nurse 94
Moderate Private Home – Intermediate Care Facility (ICF) for the DD Home 11
Moderate Program of All-Inclusive Care for the Elderly (PACE) 89
Limited Provider Eligibility Verification Only 83
Limited Psychiatric Rehabilitation 87
Limited Psychologist - Counselor 49
Limited Public Health Department Clinic 51
Limited Qualified Medicare Beneficiary (QMB) Only Service 75
Limited Rehabilitation Center 57
Moderate Rural Health Clinic 59
Limited School Services 96
Moderate Speech Language Therapist 46
Limited State Institution – Long Term Care (LTC) 5
Limited Targeted Case Management (TCM) Foster Care 17
Moderate TCM for Intellectual/Developmental Disabilities 15
Moderate Teaching Institution 55
Limited Third Party Assessor 27
Moderate - Limited Risk Screening Requirements
- Verification that the applying provider, and all persons disclosed or required to be disclosed, meet all applicable federal regulations and MO HealthNet Program requirements for the provider type.
- Verification that the applying provider, and all persons disclosed, have a valid license, operating certificate, or certification if required for the provider type, and that there are no current limitations on such licensure, operating certificate, or certification which would preclude enrollment.
- Verification that the applying provider’s, and that of all persons disclosed, license(s) held in any other state has/have not expired and that there is/are no current limitations on such license(s) which would preclude enrollment.
- Confirmation of the identity of the applying provider and determination of the exclusion status of the applying provider and any person with an ownership or control interest or who is an agent or managing employee of the provider through routine checks of the following federal databases:
- Social Security Administration’s Death Master File
- National Plan and Provider Enumeration System
- List of Excluded Individuals/Entities
- The Excluded Parties List System
- Medicare Exclusion Database
- Any such other databases as the Secretary of the United States Department of Health and Human Services has prescribed as of September 30, 2021, pursuant to section 455.436 of Title 42, Code of Federal Regulations, which is incorporated by reference and made part of this rule as published by the Office of the Federal Register, 7 G Street NW, Suite A-734, Washington, DC 20401. This rule does not incorporate any subsequent amendments and additions
- Database check of the National Sex Offender Public Website.
- The information from these databases shall be used to determine eligibility of the MO HealthNet provider and for verification of the identity of the applying person, the Social Security number, the National Provider Identifier (NPI), the National Practitioner Data Bank (NPDB) licensure, and any exclusion by the Department of Health and Human Services, Office of Inspector General.
- The information from these databases shall be used to determine eligibility of the MO HealthNet provider and for verification of the identity of the applying person, the Social Security number, the National Provider Identifier (NPI), the National Practitioner Data Bank (NPDB) licensure, and any exclusion by the Department of Health and Human Services, Office of Inspector General; and
- MMAC may conduct preapproval site visits prior to acceptance of a provider’s application. Refer to Enrollment Site Visits for more information.
- Moderate Risk Screening Requirements
- Screening requirements for the limited risk category
- Site visits prior to acceptance of an applying provider’s application
- Unannounced post-enrollment site visits
Visit Enrollment Site Visits for more information.
- High Risk Screening Requirements
- Screening requirements for the limited and moderate risk categories
- Fingerprint-based criminal background check of individual providers or in the case of an institutional provider, every person with a 5% or more ownership interest in the provider.
For more information, review Fingerprint Based Criminal History Checks.