A Provider’s Guide to Washington State Medicaid

This guide is intended to assist Apple Health providers on exclusion and sanction screening obligations for anyone whose role could affect Medicaid billings or deliverables — clinical and non-clinical — and describes how to screen, document, remediate, and report matches.

Washington’s Medicaid program, also known as Apple Health imposes significant exclusion and sanction-screening obligations on providers. In practice this means providers must screen employees, contractors, volunteers, subcontractors and other persons or entities who touch Medicaid billings or services against Washington’s HCA/DSHS termination and exclusion lists and the federal exclusion sources (OIG’s LEIE and SAM) — typically at hire/engagement and monthly thereafter. 

Authorities, Definitions, and Quick Links

• Washington Administrative Code (WAC): WAC 182-502-0030; WAC 388-113-0020; WAC 388-113-0030; WAC 388-71-0540 (state rules governing termination and exclusion).
  
• Federal law/regulation: 42 CFR Part 1001 (OIG exclusion authorities); Affordable Care Act §6501 (if excluded in one state, excluded everywhere for Federal healthcare programs).
  
• Federal lists: OIG List of Excluded Individuals/Entities (LEIE); System for Award Management (SAM) exclusions.
  
• State lists: Apple Health has two provider termination and exclusion lists. Washington Health Care Authority Provider Termination and Exclusion list(HCA); Department of Social and Health Services social services provider listing (DSHS).
  

What are the Basic Washington Medicaid Exclusion Screening Requirements?

Washington is one of the forty-five states and the District of Columbia that maintains its own separate Medicaid Exclusion List. These lists generally serve the unified purpose of barring sanctioned individuals and entities from participating in the state’s Medicaid program. 

Providers must screen all employees and contractors against several federal databases in addition to Washington Medicaid’s two state-maintained databases prior to hiring and monthly thereafter to ensure that none have been excluded from participation in the program since the last search. 

The lists include

Washington Medicaid’s termination and exclusion lists that include Individuals or entities whose participation in the Medicaid program has been terminated for cause under specific Washington Administrative Code (WAC) provisions (WAC 182-502-0030, WAC 388-113-0020, WAC 388-113-0030, and WAC 388-71-0540). Medicaid providers who have been excluded from participation under Federal regulation (42 CFR 1001).

1. HCA Provider Termination & Exclusion list — Washington Health Care Authority website. Search the HCA site for “Provider Termination and Exclusion” or navigate through the Provider Enrollment/Provider relations sections. This list is updated periodically, with a noted update date of October 10, 2025. 
2. DSHS Social Services Providers Listing — Washington State Department of Social and Health Services (DSHS).

Federal Lists

3. OIG LEIE — Office of Inspector General (HHS) Exclusions search. (LEIE is the federal exclusions register.)
4. SAM Exclusions — System for Award Management (GSA) — search exclusions.
   Other state exclusion lists — recommended to screen other states where your organization performs services or where payers require multi-state certification.

Screening Frequency

Screening employees, contractors, and vendors against the federal and state lists is universally required upon hire (before the person provides billable services) and monthly thereafter to avoid civil money penalties. CMS guidance and ACA expectations require monthly screening to reduce CMP risk. Monthly must be documented.

Other screening requirements are on the change of role or provider enrollment status and immediately upon any notification of an exclusion or sanction.

Consequences of Non-Compliance in Washington Medicaid

If a provider employs or contracts with an excluded individual or entity, they face significant risks:

• Payment Prohibition: Federal health care programs, including Medicaid, will not pay for any item or service furnished directly or indirectly by, or at the medical direction or on the prescription of, an excluded person. Any nonenrolled provider, including any provider terminated from the Medicaid Program, is not permitted to provide services to Medicaid recipients.
• Overpayments: Any payments made by the Medicaid program for services provided directly or indirectly by an excluded party are considered overpayments subject to recovery.
• Civil Money Penalties (CMPs): Penalties may be imposed for knowingly contracting with an excluded party or submitting claims for services furnished by an excluded individual. Failure to screen monthly can risk CMP liability.
• Exclusion/Termination: Exclusion screening is a condition of provider enrollment, and failure to screen risks suspension or termination from the Medicaid program. Exclusion in one state (or termination for cause) can trigger sanctions in all other states.

The payment prohibition applies broadly to nearly anyone involved in providing an item or service payable by a Federal health care program. This includes individuals performing administrative, management, IT, transportation, and billing services, even volunteers, unless their contributions are “wholly unrelated” to the Federal health care program payment.

Best Practices for Complying with Washington State Medicaid (Apple Health)

Compliance with exclusion and termination screening requirements under Washington’s Apple Health program is critical. Providers who fail to verify the exclusion status of their owners, officers, managers, employees, and contractors risk overpayment liability, the imposition of civil money penalties (CMPs), termination from the Medicaid program, and potential cross-state exclusion under federal law. Only consistent and properly documented screening can protect providers from these risks. The following best practices are recommended for inclusion in every provider’s compliance plan.

Screen All Employees, Contractors, and Vendors

Washington Medicaid (Apple Health) does not pay for any items or services furnished — directly or indirectly — by an excluded individual or entity.
This payment prohibition applies broadly to anyone whose work contributes to federally reimbursed services, including administrative staff, IT personnel, billing vendors, and even unpaid volunteers.

A good rule of thumb:

If an individual or vendor has access to Medicaid patients, facilities, patient records, or financial systems tied to Apple Health payments, they must be screened.

Providers should screen each person or entity:

• Before hire or contract initiation, and
  
• Monthly thereafter, in accordance with CMS guidance and Washington’s screening policy.

Owner, Officer, Manager, and Director Screening

Ownership and leadership screening is essential.
Washington Administrative Code (WAC 182-502-0030) authorizes the Health Care Authority (HCA) to deny, suspend, or terminate a provider’s enrollment if the provider, or any officer, director, partner, managing employee, or owner, has been sanctioned, excluded, or terminated by any state or federal health care program.

WAC 182-502-0030(4) – The HCA may deny, suspend, or terminate a provider’s participation if the provider, or any person with an ownership or control interest, is excluded from participation in Medicare, Medicaid, or any other state or federal health care program.

Therefore, all owners, officers, directors, and managing employees must be screened prior to enrollment and monthly thereafter against both state and federal exclusion databases.

Special Rules for Billers and Coders

Billing staff and third-party billing companies receive special scrutiny from regulators and auditors because of their direct involvement in claims submitted to Apple Health.
Providers may delegate screening activities to billing contractors; however, the legal responsibility remains with the provider.
The Office of Inspector General (OIG) and Centers for Medicare & Medicaid Services (CMS) recommend adopting the following best practices:

1. Require all billing contractors to maintain and enforce a written policy prohibiting the employment or use of excluded individuals.
   
2. Require billing contractors to screen their employees upon hire and monthly thereafter and maintain documentation of this process.
   
3. Require billing contractors to provide periodic training on exclusion screening, documentation, and claim submission compliance.
   
4. Obtain annual written attestations from billing companies confirming their compliance with exclusion screening obligations.

Failure of a billing vendor to comply does not shield the provider from liability for overpayments or sanctions.

Screening Must Be Conducted at Hire or Contract Initiation, and Monthly Thereafter

Both federal regulations and Washington state guidance require that screening be conducted upon hire and repeated monthly thereafter.

• Federal authority: 42 CFR § 1001.1901(b) and CMS State Medicaid Director Letter #09-001 establish monthly screening expectations for all Medicaid providers.
  
• State authority: Washington HCA and DSHS direct providers to perform monthly screening against both state and federal lists to maintain enrollment and avoid payment suspension.

Providers Should Consider Hiring a Vendor to Fulfill Exclusion Screening Requirements

Although small providers may be able to manually check the HCA, DSHS, OIG, and SAM lists upon hire and monthly thereafter, many find the process increasingly complex — particularly when screening across multiple states, or managing large volumes of employees and contractors.

Challenges include:

• Lack of uniform data formats (Excel, PDF, or HTML)
  
• Inconsistent identifiers (some lists contain only names or cities)
  
• Frequent updates to federal and state databases
  
• Duplicate or similar names requiring manual investigation
  

To ensure complete, accurate, and timely screening, providers should consider using a specialized exclusion screening vendor. Even when a vendor performs the screening, providers must maintain final responsibility for compliance, documentation, and any resulting overpayments.

Final Thoughts

The goal of this article was to help providers gain a better understanding of Medicaid Exclusions in Washington state.  Exclusions are imposed on people and entities that pose risks to the Program and its beneficiaries, and that is why Washington Medicaid will not pay for any item or service furnished by them, whether directly or indirectly. The article is also intended to help providers gain an understanding of their exclusion screening obligations and how they can fulfill them.