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Sector Map · as of 2026-10-08

A Medicaid managed care plan

Who this is for: MCOs and their network, credentialing and compliance teams, any state

Why these forms: 42 CFR 438.608 and 438.610 put network providers, owners and subcontractors under screening and disclosure; the state's 455.436 check and the plan's own monthly read are two records of the same duty.

3 form lines · sources read: leie, nppes, sam, state · SHA-256 885841ef9e76dd53… · printable / PDF

CMS-855A · 855B · 855I · 855S — CMS-855A / 855B / 855I / 855S Medicare Enrollment Applications — Section 3 Final Adverse Legal Actions

The line: Section 3 asks the applicant to list exclusions, debarments, revocations and license suspensions; 42 CFR 424.516 requires reporting changes within 30 days; 42 CFR 424.535 lists revocation grounds.

Citation: 42 CFR 424.516; 42 CFR 424.535; 42 CFR 1001.1901

Duty Sheet: 42 CFR 455.436 — Federal database checks (Medicaid provider screening); HHS-OIG General Compliance Program Guidance — exclusion screening of employees, medical staff and vendors

  • Step 2: The state agency checks the provider and every disclosed person against the OIG LEIE and SAM Exclusions at enrollment and re-enrollment. — 42 CFR 455.436(b)
  • Step 3: The state agency repeats the LEIE and SAM check monthly. — 42 CFR 455.436(c)(2)
  • Step 4: No federal program payment for items or services furnished, ordered or prescribed by an excluded person; providers check their own staff and contractors. — 42 CFR 1001.1901(b); 42 CFR 438.610; OIG Special Advisory Bulletin on the Effect of Exclusion (2013)
  • Step 5: Managed care plans screen and the state enrolls network providers; plans report excluded or terminated providers. — 42 CFR 438.608(b)–(c)

What a read cannot prove: Identity (a name match is a candidate); whether a disclosure was owed; the outcome of enrollment.

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

The line: 455.436(b)–(c): the state agency checks the LEIE and SAM exclusions at enrollment, re-enrollment and monthly thereafter; 455.104–106: the provider discloses owners, managing employees and convictions on the state's form.

Citation: 42 CFR 455.436; 42 CFR 455.104–455.106

Duty Sheet: 42 CFR 455.436 — Federal database checks (State Medicaid agency side); 42 CFR 455.436 — Federal database checks (Medicaid provider screening)

  • Step 2: The state agency checks the provider and every disclosed person against the OIG LEIE and SAM Exclusions at enrollment and re-enrollment. — 42 CFR 455.436(b)
  • Step 3: The state agency repeats the LEIE and SAM check monthly. — 42 CFR 455.436(c)(2)
  • Step 4: No federal program payment for items or services furnished, ordered or prescribed by an excluded person; providers check their own staff and contractors. — 42 CFR 1001.1901(b); 42 CFR 438.610; OIG Special Advisory Bulletin on the Effect of Exclusion (2013)
  • Step 5: Managed care plans screen and the state enrolls network providers; plans report excluded or terminated providers. — 42 CFR 438.608(b)–(c)

What a read cannot prove: Enrollment status; that disclosed owners were screened; identity behind a name match.

42 CFR 438.608(b)–(c) — Medicaid managed care plan — network provider screening, enrollment and ownership disclosure attestation to the state

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

Duty Sheet: 42 CFR 455.436 — Federal database checks (Medicaid provider screening); CMS Medicare Advantage / Part D compliance program — first-tier, downstream and related entity (FDR) exclusion screening

  • Step 2: The state agency checks the provider and every disclosed person against the OIG LEIE and SAM Exclusions at enrollment and re-enrollment. — 42 CFR 455.436(b)
  • Step 3: The state agency repeats the LEIE and SAM check monthly. — 42 CFR 455.436(c)(2)
  • Step 4: No federal program payment for items or services furnished, ordered or prescribed by an excluded person; providers check their own staff and contractors. — 42 CFR 1001.1901(b); 42 CFR 438.610; OIG Special Advisory Bulletin on the Effect of Exclusion (2013)
  • Step 5: Managed care plans screen and the state enrolls network providers; plans report excluded or terminated providers. — 42 CFR 438.608(b)–(c)

What a read cannot prove: Enrollment status with the state; ownership disclosures; identity behind a name match.

A reference map, not a receipt and not advice: the forms whose lines a dated public-record receipt supports for this kind of organisation, the Duty Sheet behind each, the official record each rests on, how this platform reads it, and what a read cannot prove. Whether a given line applies to a given organisation is decided by its awards, contracts and agencies — not here.

Cite as: Alpha Covenant Holdings, Sector Map: A Medicaid managed care plan (as of 2026-10-08), https://alphacovenantholdings.com/maps/medicaid-mco. 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. · All maps

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