Medicaid exclusion screening: federal and state sources

Federal exclusion status and state Medicaid status are separate checks

Medicaid exclusion screening compares people and entities with the sources relevant to their participation in Medicaid. The federal HHS OIG List of Excluded Individuals and Entities (LEIE) identifies OIG exclusions from federal health care programs, including Medicaid. A state Medicaid agency may separately exclude or restrict providers under its own authority. A clear federal search does not establish eligibility in every state program.

State sources can describe exclusions, terminations, or other restrictions; those terms do not always describe the same action. Check the issuing agency, effective dates, reinstatement information, and scope of the record before deciding what it means for your organization.

Federal award exclusions in SAM.gov serve a different scope from the LEIE. The Medicaid agency rule below names EPLS, the predecessor to SAM exclusions. Follow the databases specified by your applicable rules and contracts; a SAM search does not replace the LEIE or state checks.

Who is responsible, and how often should checks run?

42 CFR § 455.436 requires state Medicaid agencies to verify providers and people with ownership or control interests, agents, and managing employees through federal databases. Agencies must confirm identity at enrollment and reenrollment and check LEIE and EPLS at least monthly. The published CFR text also lists the Death Master File and NPPES among the databases checked. These are agency duties, not a universal monthly workforce-screening rule for every provider.

The OIG exclusion advisory bulletin explains that federal law sets no particular LEIE-check frequency for providers. OIG recommends checks before hiring or contracting and periodically afterward; monthly checks best reduce potential overpayment and penalty exposure. State rules and payer contracts can impose additional duties.

The bulletin also explains that the federal payment prohibition can reach indirect services, including some administrative work. Assess employees, contractors, subcontractors, and vendors by their work and funding. Assign a compliance owner for source selection, scheduling, and match resolution. Delegating searches to a staffing agency or screening service does not remove the provider’s potential liability.

A repeatable Medicaid screening workflow

1. Map your obligations. Record Medicaid programs, operating states, relevant roles, provider agreements, and managed care requirements. Identify each required source and the authority for the chosen schedule.

2. Prepare the roster. Collect accurate individual and entity names, former names, and identifiers through approved secure processes. Define who supplies updates when staff, ownership, or contracts change.

3. Search current sources. Run pre-engagement and recurring checks on the documented schedule. Record unavailable sources as incomplete checks and assign a retry rather than reporting a clear result.

4. Verify possible matches. A name match alone does not establish identity. Use the issuing agency’s verification process; OIG instructs users to verify LEIE matches with SSN or EIN in its online search. Escalate unresolved identities.

5. Resolve and close. Record the reviewer’s decision and evidence. For confirmed exclusions, involve compliance and counsel promptly to assess payment, reporting, and corrective action. OIG reinstatement is not automatic when the exclusion period ends; verify eligibility with each relevant authority.

Follow OIG’s search and identity-verification instructions. If you maintain a local LEIE copy, OIG recommends downloading the updated complete database for accuracy; monthly supplements contain only that month’s exclusions and reinstatements.

Document the check and its resolution

OIG instructs users to retain initial searches and follow-up verification. A practical record for each run should include:

• Roster scope, names searched, screening date, and person running the check.
• Each source, list version or retrieval date, and any unavailable source or retry.
• Results, verification evidence, reviewer, and reasons for clearing a possible match.
• Escalations, corrective actions, outstanding tasks, and final resolution dates.
• Reports or attestations supporting checks delegated to vendors.

Set retention and access controls using applicable state rules, contracts, and your records policy. Protect sensitive identifiers and retain only what the process needs. A negative result describes the sources and dates checked; it does not guarantee future eligibility or complete credentialing.

State-specific Medicaid resources

Start with the guides currently published below, then confirm requirements with the linked state agencies. This is a selection of resources, not a directory of every state or a statement that the same rules apply nationwide.

• Kentucky screening guide
• New Jersey screening guide
• Texas screening guide