State Medicaid Exclusion Lists

How are State Medicaid Exclusion Lists different from the OIG-LEIE?

States must notify the Health and Human Services (HHS) Office of Inspector General (OIG) of actions taken on a provider for violations of federal law. States are not required to notify the OIG of actions taken on a provider for violations of state laws. This is because if the state action does not meet federal exclusion criteria, the OIG will not include it in the OIG-LEIE.

For instance, a state might exclude someone or an entity for failing to pay state taxes or for other reasons that would not meet federal exclusion criteria. For this reason, states maintain lists of individuals and entities that are terminated, suspended, sanctioned, or otherwise excluded from the state Medicaid program.

Do state exclusion lists include the same information as the OIG-LEIE?

You’d think we would have a standard for something this important, but sadly, no. Information in state exclusion lists can vary widely, with some including little more than a name and address. Some state lists are in Excel format, others in Word or PDF, and some are simply HTML web pages.

HealthProviders DB brings together all state and federal databases into one cohesive platform, making access to healthcare information easier and more efficient!

Why do some states not keep an exclusion list?

States are not required to maintain a state exclusion list.

New Mexico, Oklahoma, Rhode Island, South Dakota, Utah, Virginia, and Wisconsin do not maintain a state Medicaid exclusion list.

HealthProviders DB collects and aggregates exclusions from all state Medicaid exclusion lists, the Office of Inspector General’s List of Excluded Individuals/Entities (OG-LEIE), and the System for Award Management (SAM). So although there is no state exclusion list, you can search HealthProviders DB for exclusions in those states.

Why do I need to screen against all state exclusion lists?

Section 6501 of the Affordable Care Act (ACA), Termination of Provider Participation Under Medicaid if Terminated Under Medicare or Other State Plan, requires State Medicaid programs and the Children’s Health Insurance Program (CHIP) to terminate the participation of any individual or entity that has been terminated from Medicare by CMS or any other State’s Medicaid program for cause.

This provision is intended to enhance program integrity by ensuring that federal funds do not reach providers excluded for serious offenses, such as fraud or abuse, regardless of the originating state’s termination.

Do You Need a One-Time Exclusion Screening?

One-time Exclusion Screening is a healthcare compliance batch exclusion screening service that compares your list of healthcare providers against the OIG LEIE, SAM, CMS, NPI, FDA, and State Medicaid exclusion lists, delivering a consolidated & comprehensive downloadable exclusion screening report—starting at just $25 for up to 100 providers screened.

One-time Exclusions Screening is useful for new provider onboarding, credentialing, vendor screening, or periodic compliance checks. It’s ideal for small organizations with a limited number of providers that want to verify exclusions and gather documented evidence themselves.

One-time Exclusions Screening is used for:

• New provider onboarding
• A compliance review
• An internal audit
• Credentialing
• Enrollment
• Vendor screening
• Contracting
• Periodic compliance checks
• A specific provider population

Do You Need Continuous Exclusion Monitoring?

Continuous Exclusion Monitoring automatically checks your monitored provider list against updated exclusion data as new source data becomes available and notifies you when a provider’s exclusion status changes.

Continuous Exclusion Monitoring Features include:

• Easily manage your list of all healthcare providers, employees, vendors, and contractors for continual exclusion monitoring.
• Automatic monthly updates imported from OIG, SAM, and State Medicaid Exclusion Lists and matched to your provider list.
• Automatic Exclusions Change Notifications.
• Comprehensive, always-current, and audit-ready Exclusions Report available for download anytime.
• Exclusions Dashboard with total Providers, Exclusions, Verifications, Reinstatements, Medicare Opt-out, and NPI deactivations.
• Built-in Exclusion Primary Source Verification Tools.
• Save Notes & Documented Evidence of Exclusion Screening.

One-time Screening vs. Continuous Exclusion Monitoring

	One-Time Screening	Continuous Monitoring
Best for	Occasional screening	Ongoing compliance
Provider list	Upload when needed	Continuously maintained
OIG LEIE	✓	✓
SAM	✓	✓
State Medicaid	✓	✓
Recurring monitoring	—	✓
Automatic change alerts	—	✓
Monitoring dashboard	—	✓
Saved screening evidence	—	✓
Price	$25/100 providers	$89 Monthly subscription

What Databases Are Checked?

HealthProviders DB is a national healthcare provider database with over 9 million profiles—updated daily directly from publicly available state and federal databases—including the complete NPI database & deactivated numbers list, OIG LEIE, SAM, CMS Revoked Medicare Providers & Medicare Opt-out, all State Medicaid Sanctions, Suspensions, Terminations, and Exclusion lists, plus state license active status, and state licensing board disciplinary actions, FDA debarments, and Clinical Investigator Disqualifications.

Database	What it identifies
OIG LEIE	Individuals and entities excluded from federal healthcare programs
SAM.gov	Federal exclusions and debarments
State Medicaid	State-specific Medicaid exclusions, terminations, and sanctions
State Licenses	State-specific licensing and disciplinary actions
CMS	Medicare opt-outs and revoked providers
FDA	FDA debarments and clinical investigator disqualifications
NPI	NPI deactivation status

Frequently Asked Questions

Who should be included in Exclusion Screening?

Healthcare organizations must screen all individuals and entities that provide items or services payable by federal health care programs. This requirement applies to anyone whose work supports services reimbursed by Medicare or Medicaid—whether those services are provided directly or indirectly.

Healthcare Providers & Facilities

Hospitals, nursing homes, home health agencies, clinics, and physician practices.

Personnel

All employees (clinical and non-clinical), pharmacists, pharmacy staff, physicians, nurses, clinical staff, medical assistants, and administrative staff.

Contractors & Vendors

Third-party billing & coding services, transportation providers, ambulance services, and medical equipment suppliers.

Leadership & Support

Board members, managers, owners, and volunteers.

Basically, if an individual’s role contributes in any way to federally reimbursable services, that individual should be included in your OIG exclusion screening and Medicare exclusion monitoring process.

What happens when an exclusion for the provider is found?

You should verify and document all matches, as evidence of provider screening, for audit review. Pay special attention to potential matches by name only and verify against other identifying information such as NPI, name, address, and license information. You can find detailed provider information in the HealthProviders DB provider profile. The Exclusions Report includes a link to the provider’s profile.

Verify the exclusion with the primary-source government record and document the findings. Confirm whether the exclusion matches the primary-source record or is a false positive; either way, document your findings. HealthProviders DB includes a link to the primary-source exclusion record for each match in the Exclusion Report to help with verification.

The HealthProviders DB Continuous Exclusions Monitoring subscription lets you save exclusion screening verification notes and documents with the provider exclusion, and they are included with the Exclusions Report for audit review.

You should review the Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs for additional guidance. If you find a confirmed exclusion match for an already employed individual or contractor, you should review the Self-Disclosure Protocol to help minimize any potential CMP.

Organizations should follow their compliance procedures and applicable requirements.

Can a name match be a false positive?

Yes. A name match alone does not necessarily mean that a provider is excluded. Review potential matches using additional identifying information such as NPI, name, address, and license information, and verify them against the applicable primary-source record.

Can I monitor employees and contractors?

Yes. You can use continuous monitoring for employees, contractors, and other individuals or entities your organization has determined should be included in its exclusion-screening process.

Can I monitor vendors?

Yes. Organizations can include vendors and other business relationships when those parties fall within the organization’s screening requirements. The appropriate scope depends on the organization’s programs, contracts, payer requirements, and applicable laws and regulations.

Can I verify an exclusion against the original government source?

Yes. HealthProviders DB provides links to applicable primary-source records so you can investigate potential matches and verify them against the underlying government source before your organization takes action.

Can I document what I did after reviewing a potential exclusion?

Yes. HealthProviders DB lets you save screening notes and documented verification evidence with the provider exclusion, and these are included in the exclusion report, helping your organization maintain a record of its screening and verification activity.

What information is included in the Exclusions Report?

The Exclusions Report includes provider name and address, NPI and deactivation information, license information, Medicare opt-out information, exclusion dates and reasons, reinstatement information, match status, and links to primary-source records for verification.

Can I start with one-time screening and switch to continuous monitoring?

Yes. A one-time screening can establish an initial baseline for a provider population. If your organization then needs ongoing monitoring, it can use the provider list for continuous exclusion monitoring to identify subsequent changes.

Does continuous monitoring replace my organization’s compliance program?

No. Continuous exclusion monitoring is a screening and monitoring tool. It does not replace your organization’s compliance policies, legal obligations, credentialing procedures, or professional judgment. Organizations should determine which individuals and entities need screening and what actions are required when they identify a potential exclusion or other status change.

What if I need help?

We are here to help you. Contact us with any questions and support you need. We can help you upload your provider list and show you how to use the verification tools to verify exclusions and document your screening evidence.

Resources

Code of Federal Regulations (CFRs) applicable to Program Integrity (not an all-inclusive list):

• 42 CFR 438 – Managed Care
• 42 CFR 455 – Program Integrity: Medicaid
• 42 CFR 456 – Utilization Control
• 42 CFR 1001 – Program Integrity – Medicare and State Health Care Programs
• 42 CFR 1002 – Program Integrity – State Initiated exclusions from Medicaid
• 42 CFR 1007 – State Medicaid Fraud Control Units

HealthProviders DB provides data and screening services to assist organizations with exclusion screening and compliance processes. Organizations should independently review and verify screening results, especially when a potential match is identified. The service does not constitute legal, regulatory, or compliance advice and does not guarantee that an organization will satisfy its legal or regulatory obligations.