Managed Care
CMS Guidance Addresses Medicaid Provider Enrollment and MCO Credentialing Standards
Chapter 7 of a CMS guidance document covers Medicaid provider enrollment and managed care organization credentialing requirements. The guidance addresses processes designed to ensure enrollees receive care from qualified providers while preventing enrollment of providers with criminal records related to federal health programs or histories of fraud, waste, or abuse. The content applies to state Medicaid agencies administering provider enrollment and managed care plans conducting credentialing. It clarifies federal expectations for screening and enrollment standards that affect provider network composition and compliance obligations.
Why it mattersMCOs must align credentialing processes with federal screening standards to maintain compliant provider networks and avoid enrolling excluded or high-risk providers.