Government forms register · Each state Medicaid agency (CMS rule)
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
Alpha Covenant Holdings, Government Forms Register: 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 (Each state Medicaid agency (CMS rule)); citation 42 CFR 455.436; 42 CFR 455.104–455.106; read 2026-10-08. https://alphacovenantholdings.com/forms/medicaid-455
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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 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
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 455.104 — § 455.104 Disclosure by Medicaid providers and fiscal agents: Information on ownership and control. · as of 2026-10-20 · last amended 2024-02-27
(a) Who must provide disclosures. The Medicaid agency must obtain disclosures from disclosing entities, fiscal agents, and managed care entities. (b) What disclosures must be provided. The Medicaid agency must require that disclosing entities, fiscal agents, and managed care entities provide the following disclosures: (1)(i) The name and address of any person (individual or corporation) with an ownership or control interest in the disclosing entity, fiscal agent, or managed care entity. The address for corporate entities must include as applicable primary business address, every business location, and P.O. Box address. (ii) Date of birth and Social Security Number (in the case of an individual). (iii) Other tax identification number (in the case of a corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or managed care entity) or in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a 5 percent or more interest. (2) Whether the person (individual or corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or managed care entity) is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling; or whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a 5 percent or more interest is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling. (3) The name of any other disclosing entity (or fiscal agent or managed care entity) in which an owner of the disclosing entity (or fiscal agent or managed care entity) has an ownership or control interest. (4) The name, address, date of birth, and Social Security Number of any managing employee of the disclosing entity (or fiscal agent or managed care entity). (c) When the disclosures must be provided—(1) Disclosures from providers or disclosing entities. Disclosure from any provider or disclosing entity is due at any of the following times: (i) Upon the provider or disclosing entity submitting the provider application. (ii) Upon the provider or disclosing entity executing the provider agreement. (iii) Upon request of the Medicaid agency during the re-validation of enrollment process under § 455.414. (iv) Within 35 days after any change in ownership of the disclosing entity. (2) Disclosures from fiscal agents. Disclosures from fiscal agents are due at any of the following times: (i) Upon the fiscal agent submitting the proposal in accordance with the State's procurement process. (ii) Upon the fiscal agent executing the contract with the State. (iii) Upon renewal or extension of the contract. (iv) Within 35 days after any change in ownership of the fiscal agent. (3) Disclosures from managed care entities. Disclosures from managed care entities (MCOs, PIHPs, PAHPs, and HIOs), except PCCMs are due at any of the following times: (i) Upon the managed care entity submitting the proposal in accordance with the State's procurement process. (ii) Upon the managed care entity executing the contract with the State. (iii) Upon renewal or extension of the contract. (iv) Within 35 days after any change in ownership of the managed care entity. (4) Disclosures from PCCMs. PCCMs will comply with disclosure requirements under paragraph (c)(1) of this section. (d) To whom must the disclosures be provided. All disclosures must be provided to the Medicaid agency. (e) Nursing facilities. (1) In addition to all other applicable reporting requirements in this subpart, a nursing facility (as defined in section 1919(a) of the Act) must disclose upon initial enrollment and revalidation the following information: (i) Each member of the governing body of the facility, including the name, title, and period of service for each such member. (ii) Each person or entity who is an officer, director, member, partner, trustee, or managing employee (as defined in § 455.101) of the facility, including the name, title, and period of service of each such person or entity. (iii) Each person or entity who is an additional disclosable party of the facility (as defined in § 455.101). (iv) The organizational structure (as defined in § 455.101) of each additional disclosable party of the facility and a description of the relationship of each such additional disclosable party to the facility and to one another. (2) The State need not require the facility to disclose the same information described in this paragraph (e) more than once on the same enrollment application submission. (f) Consequences for failure to provide required disclosures. Federal financial participation (FFP) is not available in payments made to a disclosing entity that fails to disclose ownership or control information as required by this section. [76 FR 5967, Feb. 2, 2011, as amended at 88 FR 80169, Nov. 17, 2023]
Amended: 2017-01-01, 2024-02-27 · SHA-256 of the XML as served: fa1df184e9691204987d5a5004876ea27ad04864ab8f6480b5c19672bcdb11ef · 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.
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