C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 455—PROGRAM INTEGRITY: MEDICAID › Subpart E—Provider Screening and Enrollment

42 C.F.R. § 455.416

Termination or denial of enrollment

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The State Medicaid agency—

(a) Must terminate the enrollment of any provider where any person with a 5 percent or greater direct or indirect ownership interest in the provider did not submit timely and accurate information and cooperate with any screening methods required under this subpart.

(b) Must deny enrollment or terminate the enrollment of any provider where any person with a 5 percent or greater direct or indirect ownership interest in the provider has been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or title XXI program in the last 10 years, unless the State Medicaid agency determines that denial or termination of enrollment is not in the best interests of the Medicaid program and the State Medicaid agency documents that determination in writing.

(c) Must deny enrollment or terminate the enrollment of any provider that is terminated on or after January 1, 2011, under title XVIII of the Act or under the Medicaid program or CHIP of any other State, and is currently included in the termination database under § 455.417.

(d) Must terminate the provider's enrollment or deny enrollment of the provider if the provider or a person with an ownership or control interest or who is an agent or managing employee of the provider fails to submit timely or accurate information, unless the State Medicaid agency determines that termination or denial of enrollment is not in the best interests of the Medicaid program and the State Medicaid agency documents that determination in writing.

(e) Must terminate or deny enrollment if the provider, or any person with a 5 percent or greater direct or indirect ownership interest in the provider, fails to submit sets of fingerprints in a form and manner to be determined by the Medicaid agency within 30 days of a CMS or a State Medicaid agency request, unless the State Medicaid agency determines that termination or denial of enrollment is not in the best interests of the Medicaid program and the State Medicaid agency documents that determination in writing.

(f) Must terminate or deny enrollment if the provider fails to permit access to provider locations for any site visits under § 455.432, unless the State Medicaid agency determines that termination or denial of enrollment is not in the best interests of the Medicaid program and the State Medicaid agency documents that determination in writing.

(g) May terminate or deny the provider's enrollment if CMS or the State Medicaid agency—

(1) Determines that the provider has falsified any information provided on the application; or

(2) Cannot verify the identity of any provider applicant.

[73 FR 77951, Dec. 19, 2008, as amended at 88 FR 79552, Nov. 16, 2023; 90 FR 55619, Dec. 2, 2025]
Notes of Decisions
Cited in 5 cases (1 in the last 5 years), 2020–2021 · leading case: Planned Parenthood of Grt TX v. Courtney Ph, 981 F.3d 347 (5th Cir. 2020).
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Planned Parenthood of Grt TX v. Courtney Ph, 981 F.3d 347 (5th Cir. 2020). “1615 of this subchapter (relating to Appeals) unless the termination is required under 42 C.F.R. § 455.416 .”). 94 42 U.S.C. § 1396a(a)(3).”
Colwell v. Managed Care of North Am., 308 Neb. 597 (Neb. 2021). “A termination or exclusion appealed before its effective date will not take effect until the appeal has been decided, unless the termination or exclusion is being imposed pursuant to 42 C.F.R. 455.416(c) or has an immediate effective date because of a threat to client health and…”
Planned Parenthood of Grt TX v. Courtney Ph (5th Cir. 2020). “1703(f)(2) (2020) (“A person may request an administrative hearing after receipt of a final notice of termination in accordance with § 371.”
Planned Parenthood of Grt TX v. Courtney Ph (5th Cir. 2020). “1703(f)(2) (2020) (“A person may request an administrative hearing after receipt of a final notice of termination in accordance with § 371.”
Planned Parenthood of Grt TX v. Courtney Ph (5th Cir. 2020). “1703(f)(2) (2020) (“A person may request an administrative hearing after receipt of a final notice of termination in accordance with § 371.”
— 42 C.F.R. § 455.416(c) — 1 case
Colwell v. Managed Care of North Am., 308 Neb. 597 (Neb. 2021). “A termination or exclusion appealed before its effective date will not take effect until the appeal has been decided, unless the termination or exclusion is being imposed pursuant to 42 C.F.R. 455.416(c) or has an immediate effective date because of a threat to client health and…”
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