How To: Resolve Red Exclusion Match Alerts

Resolving Matched Exclusion Alerts

Exclusions occur for a variety of reasons, including fraud, drug abuse, licensure issues, healthcare-related misdemeanors or felonies, and defaults on federally backed student loans. Federal and state agencies maintain exclusion lists updated regularly, prohibiting excluded individuals or entities from receiving payments from federally funded benefit programs. Below, we provide a step-by-step guide to resolving matched exclusion alerts effectively.

Matched exclusion alerts will display a Red Result Status, indicating a definitive match between a provider and an entry on a federal or state exclusion list. Due to the critical nature of these alerts, designated parties within your organization will receive an automated notification email when they occur.

Steps to Resolve a Matched Exclusion Alert

1. Review the Exclusion Details:

   • Access the alert in the Passport system to review critical details such as the exclusion source, date of action, and the reason for exclusion.

2. Verify:

   • Confirm the exclusion directly matches the provider’s information, including name, date of birth, and any other identifying details.

   • If you have any questions about the match, contact the exclusion source directly. See our exclusion source map here.

3. Update Progres Status and Notes:
   
   1. • Update the Passport progress status to In Progress while you are investigating the alert.

      • Record the actions taken within your compliance systems. This ensures proper documentation in the event of an audit.

By promptly addressing matched exclusion alerts, you protect your organization from penalties and maintain compliance with federal and state regulations.

Resolving Unable to Determine Exclusion Alerts

Some exclusions, marked as Yellow Result Status, occur when there is insufficient information to definitively match a provider to an exclusion record. These instances are common for providers with common names or older exclusion records with limited data. While further research is generally unnecessary, implementing a compliance plan to mitigate risks is recommended.

Best Practice Recommendation: Have the provider sign an affidavit confirming they have never been excluded. Retain the signed affidavit as part of your compliance records. For more details and a sample affidavit, please visit What is An Unable to Determine Exclusion? on the ProviderTrust website.