Alpha Covenant Holdings · Government Forms Register · https://alphacovenantholdings.com/forms/medicaid-455

42 CFR 455.104 · 455.105 · 455.106 · 455.436

State Medicaid provider enrollment application and disclosures (ownership and control, business transactions, criminal convictions) — one form per state

Provider enrollment and exclusion screening (42 CFR 455; 42 CFR 1001.1901) — the steps as written

#	Step	Who	When	Record	Citation
1	The provider files the state's enrollment application and discloses owners, managing employees, agents and criminal convictions.	provider	at enrollment and re-enrollment; within 35 days of a change	state enrollment form	42 CFR 455.104; 455.105; 455.106
2 ●	The state agency checks the provider and every disclosed person against the OIG LEIE and SAM Exclusions at enrollment and re-enrollment.	state Medicaid agency	at enrollment	the dated LEIE + SAM read	42 CFR 455.436(b)
3 ●	The state agency repeats the LEIE and SAM check monthly.	state Medicaid agency	monthly	the monthly series of dated reads	42 CFR 455.436(c)(2)
4 ●	No federal program payment for items or services furnished, ordered or prescribed by an excluded person; providers check their own staff and contractors.	provider; managed care plan	before hire or contract, then monthly	the dated LEIE + SAM read per person or vendor	42 CFR 1001.1901(b); 42 CFR 438.610; OIG Special Advisory Bulletin on the Effect of Exclusion (2013)
5 ●	Managed care plans screen and the state enrolls network providers; plans report excluded or terminated providers.	managed care plan	before network participation; ongoing	roster of dated reads	42 CFR 438.608(b)–(c)

● a dated receipt is the record at this step.

Keeping the file

#	Step	Record	Where
F1	At each ● step, pull the dated receipt under the party's exact name or UEI and file its receipt id with the transaction record.	receipt id (r_…) on the procurement, subaward or payment record	https://alphacovenantholdings.com/screening
F2	Anchor your own document for the step — the signed check, the certification, the memo — by its SHA-256 beside the receipt. The document stays with you; only its hash is logged.	anchor id (a_…) in the same log as the receipt	https://alphacovenantholdings.com/r/{receipt_id} → Anchor
F3	Note the retention line the file sits under and, once the trigger date is known, the date the period runs to.	the rule's own words and date (FAR 4.703/4.705 or 2 CFR 200.334)	https://alphacovenantholdings.com/api/retention/rules
F4	At period end, keep the signed file statement for the organization: every receipt and anchor, the sources read and which did not answer, the log head they chain to.	one signed page per UEI; its hash and signature verify without Alpha Covenant	https://alphacovenantholdings.com/file/{uei}

How the dated records are kept, not what they prove. A receipt shows what the official file printed on the read date; an anchor shows a document existed in that exact form on that date; the file statement lists what the file holds. None of them states that a step was done correctly or that the organization is eligible or compliant.

How the auditor tests it

CMS and HHS-OIG review whether the state agency performed the database checks at enrollment and monthly and whether excluded providers were paid. — 42 CFR 455.436; HHS-OIG audits of state Medicaid provider screening
Medicare Advantage / Part D: CMS program audits test the compliance program element for FDR exclusion screening before hire or contract and monthly. — 42 CFR 422.503(b)(4)(vi)(F); CMS Program Audit Protocol — Compliance Program Effectiveness

The steps as the regulation and the auditor's program state them, each with its citation. Nothing here is advice or a determination; the agency's text controls. A dated receipt is the record at the marked steps — it shows what the official file printed on the read date, not that the step was done correctly.

Not legal advice, not a compliance determination, not a statement that any filer's certification is true or false. Form numbers and line numbers are as published on the date noted and may be renumbered by their agencies; the official page controls. Audit findings quoted are the auditor's words as filed at the Federal Audit Clearinghouse, cited by report id; they describe a documentation gap, not a conclusion about any party.