Provider Assigned Risk Categories

State and federal regulations (13 CSR 65-2 and 42 CFR 455.450) require all Medicaid providers to be screened during their initial enrollments and revalidations, according to their assigned risk level category.  The three risk level categories are limited, moderate and high.  Any provider who is not categorized within the limited, moderate or high risk categories by the state and federal regulations mentioned above shall be screened as moderate risk providers per 13 CSR 65-2.020(9)(I).

Effective July 1, 2015 (state FY-16), MMAC will begin screening all new and revalidating MO HealthNet providers against their assigned risk category.

Provider Risk Category Table

Because MMAC will only be revalidating limited risk providers during state fiscal year 2016 and state fiscal year 2017, the only providers being screened against the moderate or high risk requirements will be newly enrolling providers.

Per 13 CSR 65-2 and 42 CFR 424.518, MMAC must adjust the categorical risk level from “Limited” or “Moderate” to “High” when any of the following occurs:

  • MMAC imposes a payment suspension on a provider based on a credible allegation of fraud, waste or abuse by the provider; the provider has an existing Medicaid overpayment; or the provider has been excluded by the federal Department of Health and Human Services (DHHS) , Office of the Inspector General or another state’s Medicaid program within the previous 10 years. The upward adjustment of the provider’s categorical risk level for a payment suspension or overpayment shall continue only so long as the payment suspension or overpayment continues; or
  • MMAC or CMS in the previous six (6) months lifted a temporary moratorium for the particular provider type and a provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider at any time within six (6) months of the date the moratorium was lifted.

Any questions regarding assigned risk categories can be submitted to