Medicaid exclusion screening requirements in Pennsylvania
What Pennsylvania Medicaid requires of the organizations that take part in it: whether the state keeps its own exclusion list, how often it expects you to check, what the penalties are, and how an action taken in another state reaches you here. Every claim on this page links to the source it came from.
Content review and source verification
- Last reviewed
- Last verified
- Content owner
- Exclia content team
- Review cadence
- Every 90 days
- Next review due
What Exclia screens for this state
Pennsylvania’s own Medicaid exclusion list is rolling out to Exclia. The federal lists (OIG LEIE and SAM.gov) are screened today.
What the state requires
Screen employees and contractors at the start of a participation relationship or contracting and monthly thereafter.
DHS instructs Medical Assistance providers in fee-for-service and managed care to screen individuals and entities using Medicheck and the federal LEIE. Federal checks remain separate; Pennsylvania’s own list does not establish comprehensive federal coverage.
Why monthly, and where the exposure comes from
The HHS Office of Inspector General publishes the federal exclusion list (the LEIE) monthly, and its guidance to providers is that screening staff and contractors each month is what best limits the risk of overpayment and civil monetary penalty liability. State Medicaid agencies are themselves required to check the LEIE no less frequently than monthly (42 C.F.R. § 455.436(c)(2)), which is the rhythm the lists move on.
The state’s own list
Medicheck Precluded Provider List
Pennsylvania keeps its own Medicaid exclusion list, separate from the federal OIG list. Searching one does not cover the other.
Medicheck publishes provider and entity participation actions for Pennsylvania Medical Assistance. Inspect status and end dates before treating an old action as a current restriction.
- Published by
- Pennsylvania Department of Human Services
- Refreshed
- DHS states the website is updated daily; the download includes sanction history., per the publishing agency.
How Exclia reads this list
Exclia reads the Pennsylvania Medicheck list (CSV).
Some rows carry action codes whose current meaning the publisher does not state. Exclia stores every row as evidence but screens none of them until those meanings are confirmed.
Whether this source is screening today, and the exact file version in use, is shown on the coverage page.
What happens if it is not done
DHS describes payment restrictions for services involving a person with a current participation restriction.
- The FAQ states DHS and managed care organizations will not pay for services prescribed, ordered or rendered by affected providers or individuals; it cites 55 Pa. Code §§ 1101.42(c) and 1101.77(c).
- The FAQ also describes restrictions for entities with at least five percent ownership by an affected provider after the action’s effective date.
The federal exposure behind the state requirement
Where a federal health care program pays for an item or service furnished, ordered, or prescribed by a person on an exclusion list, the OIG can seek repayment of what was paid, civil monetary penalties for each item or service claimed (a statutory $10,000, adjusted annually for inflation), and an assessment of up to three times the amount claimed. The standard is what the organization knew or should have known — which is why the date of your last check is the fact that matters.
How another state’s action reaches you here
Section 6501 of the Affordable Care Act (42 U.S.C. § 1396a(a)(39), implemented at 42 C.F.R. § 455.416(c)) requires a state Medicaid agency to deny or end the enrollment of any provider that was terminated for cause on or after January 1, 2011 under Medicare, or under the Medicaid or CHIP program of any other state, and that appears in the federal termination database. In practice that means an action taken against a provider in one state reaches their participation in every other — so the list that matters to you is not only your own state's.
Common questions
Use the official portal’s Download Text File button, or leave search fields blank as its instructions describe. A name-filtered search is not a complete roster. Preserve the original download and check current dates and status.
No. DHS says all sanction history is displayed. Its FAQ says a past end date means the restriction no longer applies from that date. The text export also contains reinstatement and withdrawal statuses, so the entire historical file must not become an active-only screening snapshot.
No. The FAQ cites 55 Pa. Code § 1101.82(a) and says the provider must request reenrollment. The end of an action and actual reenrollment are separate facts.
Follow DHS’s current official verification workflow and inspect the relevant end date. Keep sensitive identifier verification inside the official portal; do not send tax identifiers to Exclia or record them in screening notes.
Use the current coverage page to check actual activated data. A public source or state guide does not prove activation. The historical export requires reviewed current-status handling before live screening is enabled.
Check one name against the federal lists, free
One name, no account, and the result states which sources it covered and which it did not. It is a spot check rather than monitoring — it does not satisfy a monthly requirement on its own.
Run a free checkOr do it for the whole roster, every month
Exclia screens every person and vendor on your roster each month against the sources we cover, and keeps the dated audit trail that shows you did it.
See pricingEvery published state in one printable table, with the source for each row and a publication date you can check. Get the state-by-state requirements table
This states what each state publishes and links to where it says it. It is not legal advice, and where your own obligations are unclear your counsel is the right reader of these sources.