Government forms register · CMS / each state Medicaid agency

42 CFR 438.608(b)–(c)

Medicaid managed care plan — network provider screening, enrollment and ownership disclosure attestation to the state

Official page

www.ecfr.gov/current/title-42/section-438.608

regulation text (eCFR refuses automated reads; opens in a browser)

OMB control

not held here

OMB control number as printed on the form on 2026-10-08; where none is held here, read it from the form's own footer or the Paperwork Reduction Act notice linked under 'rule as printed'.

Filed in / who to ask

OIG List of Excluded Individuals/Entities · help: OIG Exclusions · exclusions@oig.hhs.gov

State Medicaid provider portals and exclusion lists · help: State agency pages — see the state register

All systems and help desks

Agency's instructions

www.ecfr.gov/current/title-42/section-438.608

the agency's instructions are on the official page. The agency's own instructions, linked — not paraphrased here. We quote nothing we have not read.

Cite / embed

Alpha Covenant Holdings, Government Forms Register: 42 CFR 438.608(b)–(c) — Medicaid managed care plan — network provider screening, enrollment and ownership disclosure attestation to the state (CMS / each state Medicaid agency); citation 42 CFR 438.608; 42 CFR 438.610; 42 CFR 455.436; read 2026-10-08. https://alphacovenantholdings.com/forms/mco-438-608

Link, quote and embed freely with the citation intact. The agency is the author of the form and the rule; this register is a dated reading of them. No endorsement is implied and none may be claimed.

The line

438.608(b): network providers must be screened and enrolled by the state; (c): the MCO discloses ownership and control and reports excluded or terminated providers; 438.610 prohibits relationships with excluded persons.

Citation

42 CFR 438.608; 42 CFR 438.610; 42 CFR 455.436 · www.ecfr.gov/current/title-42/section-438.608

What the receipt supports

A dated OIG LEIE + SAM + state-list receipt per network provider and the monthly series (roster).

What it does not prove

Enrollment status with the state; ownership disclosures; identity behind a name match.

Finding patterns

Provider exclusion screening not performed at enrollment or monthly

Where to read it

leie, sam, state — official pages · Duty sheets: 42-cfr-455-436, cms-fdr-oversight · Rule page

Many names at once

Roster upload — CSV of subcontractors, lower-tier subs, vendors or practitioners (names with UEI/CAGE/NPI/EIN); one dated receipt per row, a coverage table for the file, and a monthly re-read that prints only what changed. The free single receipt at /screening is identical in content.

Letter block

The form this answers: Medicaid managed care plan — network provider screening, enrollment and ownership disclosure attestation to the state (42 CFR 438.608(b)–(c)). The line: 438.608(b): network providers must be screened and enrolled by the state; (c): the MCO discloses ownership and control and reports excluded or terminated providers; 438.610 prohibits relationships with excluded persons. Citation: 42 CFR 438.608; 42 CFR 438.610; 42 CFR 455.436 — https://www.ecfr.gov/current/title-42/section-438.608. What the receipt is: A dated OIG LEIE + SAM + state-list receipt per network provider and the monthly series (roster). What it is not: Enrollment status with the state; ownership disclosures; identity behind a name match. Register: https://alphacovenantholdings.com/forms/mco-438-608

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

● a dated receipt is the record at this step · printable

#	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)

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.

Upstream — the rule as printed

42 CFR 438.608 — § 438.608 Program integrity requirements under the contract. · as of 2026-10-15 · last amended 2024-09-24

(a) Administrative and management arrangements or procedures to detect and prevent fraud, waste and abuse. The State, through its contract with the MCO, PIHP or PAHP, must require that the MCO, PIHP, or PAHP, or subcontractor to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims under the contract between the State and the MCO, PIHP, or PAHP, implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse. The arrangements or procedures must include the following:
(1) A compliance program that includes, at a minimum, all of the following elements:
(i) Written policies, procedures, and standards of conduct that articulate the organization's commitment to comply with all applicable requirements and standards under the contract, and all applicable Federal and State requirements.
(ii) The designation of a Compliance Officer who is responsible for developing and implementing policies, procedures, and practices designed to ensure compliance with the requirements of the contract and who reports directly to the Chief Executive Officer and the board of directors.
(iii) The establishment of a Regulatory Compliance Committee on the Board of Directors and at the senior management level charged with overseeing the organization's compliance program and its compliance with the requirements under the contract.
(iv) A system for training and education for the Compliance Officer, the organization's senior management, and the organization's employees for the Federal and State standards and requirements under the contract.
(v) Effective lines of communication between the compliance officer and the organization's employees.
(vi) Enforcement of standards through well-publicized disciplinary guidelines.
(vii) Establishment and implementation of procedures and a system with dedicated staff for routine internal monitoring and auditing of compliance risks, prompt response to compliance issues as they are raised, investigation of potential compliance problems as identified in the course of self-evaluation and audits, correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and ongoing compliance with the requirements under the contract.
(2) Provision for reporting within 30 calendar days all overpayments identified or recovered, specifying the overpayments due to potential fraud, to the State.
(3) Provision for prompt notification to the State when it receives information about changes in an enrollee's circumstances that may affect the enrollee's eligibility including all of the following:
(i) Changes in the enrollee's residence;
(ii) The death of an enrollee.
(4) Provision for notification to the State when it receives information about a change in a network provider's circumstances that may affect the network provider's eligibility to participate in the managed care program, including the termination of the provider agreement with the MCO, PIHP or PAHP.
(5) Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis.
(6) In the case of MCOs, PIHPs, or PAHPs that make or receive annual payments under the contract of at least $5,000,000, provision for written policies for all employees of the entity, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers.
(7) Provision for the prompt referral of any potential fraud, waste, or abuse that the MCO, PIHP, or PAHP identifies to the State Medicaid program integrity unit or any potential fraud directly to the State Medicaid Fraud Control Unit.
(8) Provision for the MCO's, PIHP's, or PAHP's suspension of payments to a network provider for which the State determines there is a credible allegation of fraud in accordance with § 455.23 of this chapter.
(b) Provider screening and enrollment requirements. The State, through its contracts with a MCO, PIHP, PAHP, PCCM, or PCCM entity must ensure that all network providers are enrolled with the State as Medicaid providers consistent with the provider disclosure, screening and enrollment requirements of part 455, subparts B and E of this chapter. This provision does not require the network provider to render services to FFS beneficiaries.
(c) Disclosures. The State must ensure, through its contracts, that each MCO, PIHP, PAHP, PCCM, PCCM entity, and any subcontractors:
(1) Provides written disclosure of any prohibited affiliation under § 438.610.
(2) Provides written disclosures of information on ownership and control required under § 455.104 of this chapter.
(3) Reports to the State within 60 calendar days when it has identified the capitation payments or other payments in excess of amounts specified in the contract.
(d) Treatment of recoveries made by the MCO, PIHP or PAHP of overpayments to providers. (1) Contracts with a MCO, PIHP, or PAHP must specify:
(i) The retention policies for the treatment of recoveries of all overpayments from the MCO, PIHP, or PAHP to a provider, including specifically the retention policies for the treatment of recoveries of overpayments due to fraud, waste, or abuse.
(ii) The process, timeframes, and documentation required for reporting the recovery of all overpayments.
(iii) The process, timeframes, and documentation required for payment of recoveries of overpayments to the State in situations where the MCO, PIHP, or PAHP is not permitted to retain some or all of the recoveries of overpayments.
(iv) This provision does not apply to any amount of a recovery to be retained under Fa
[…] full text at the eCFR link

Amended: 2017-01-01, 2024-09-24 · SHA-256 of the XML as served: 1a8cceac3306db5281ccdc0ad229bb5c312d7834efd248ca2633991a9e12ff0f · eCFR

The eCFR is an editorial compilation maintained by the Office of the Federal Register and GPO; it is updated daily and is not the official legal edition (the annual Code of Federal Regulations is). Text printed here is as the eCFR served it on the read date.

42 CFR 438.610 — § 438.610 Prohibited affiliations. · as of 2026-10-15 · last amended 2017-01-01

(a) An MCO, PIHP, PAHP, PCCM, or PCCM entity may not knowingly have a relationship of the type described in paragraph (c) of this section with the following:
(1) An individual or entity that is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in nonprocurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549.
(2) An individual or entity who is an affiliate, as defined in the Federal Acquisition Regulation at 48 CFR 2.101, of a person described in paragraph (a)(1) of this section.
(b) An MCO, PIHP, PAHP, PCCM, or PCCM entity may not have a relationship with an individual or entity that is excluded from participation in any Federal health care program under section 1128 or 1128A of the Act.
(c) The relationships described in paragraph (a) of this section, are as follows:
(1) A director, officer, or partner of the MCO, PIHP, PAHP, PCCM. or PCCM entity.
(2) A subcontractor of the MCO, PIHP, PAHP, PCCM, or PCCM entity, as governed by § 438.230.
(3) A person with beneficial ownership of 5 percent or more of the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's equity.
(4) A network provider or person with an employment, consulting or other arrangement with the MCO, PIHP, PAHP, PCCM, or PCCM entity for the provision of items and services that are significant and material to the MCO's, PIHP's, PAHP's, PCCM's, or PCCM entity's obligations under its contract with the State.
(d) If a State finds that an MCO, PIHP, PAHP, PCCM, or PCCM entity is not in compliance with paragraphs (a) and (b) of this section, the State:
(1) Must notify the Secretary of the noncompliance.
(2) May continue an existing agreement with the MCO, PIHP, PAHP, PCCM, or PCCM entity unless the Secretary directs otherwise.
(3) May not renew or otherwise extend the duration of an existing agreement with the MCO, PIHP, PAHP, PCCM, or PCCM entity unless the Secretary provides to the State and to Congress a written statement describing compelling reasons that exist for renewing or extending the agreement despite the prohibited affiliations.
(4) Nothing in this section must be construed to limit or otherwise affect any remedies available to the U.S. under sections 1128, 1128A or 1128B of the Act.
(e) Consultation with the Inspector General. Any action by the Secretary described in paragraphs (d)(2) or (3) of this section is taken in consultation with the Inspector General.

Amended: 2017-01-01 · SHA-256 of the XML as served: 3bc235463edab04ffbbd40014b96005f0898904a3ac8683f6739f2a8009d7a32 · eCFR

42 CFR 455.436 — § 455.436 Federal database checks. · as of 2026-10-20 · last amended 2017-01-01

The State Medicaid agency must do all of the following:
(a) Confirm the identity and determine the exclusion status of providers and any person with an ownership or control interest or who is an agent or managing employee of the provider through routine checks of Federal databases.
(b) Check the Social Security Administration's Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the Excluded Parties List System (EPLS), and any such other databases as the Secretary may prescribe.
(c)(1) Consult appropriate databases to confirm identity upon enrollment and reenrollment; and
(2) Check the LEIE and EPLS no less frequently than monthly.

Amended: 2017-01-01 · SHA-256 of the XML as served: 4c6c971e6dd86a39cc2d2bb3b7351f6bcda68f3a563c3f4252a86a9c10747a5a · eCFR

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