Goulter Compliance AdvisoryHealthcare Privacy & Compliance
Exhibit A · Policy E08

Exclusion Screening: Responsibility Matrix and Match Resolution Worksheet

Companion handout to the Exclusion and Sanction Screening Policy. Part 1 is for posting in the departments that run the screens. Part 2 is completed one sheet per potential match.
DRAFT TEMPLATE: NOT LEGAL ADVICE. Fill in the bracketed fields below and have your own counsel or compliance professional review this handout before putting it into use. No attorney-client or professional advisory relationship is created.
Practice[Practice Name]
Compliance Officer / Contact[Compliance Officer]
Effective Date[Effective Date]

Part 1: Who screens whomStanding assignments

Every row below is a standing assignment, not a suggestion. Where [Practice Name] has no separate department for a function, the Compliance Officer owns that row and records that assignment. Nothing in the "Screen before" column proceeds until a clear screening result is documented.
FunctionPopulation it ownsScreen beforeOngoing
Human Resources Applicants, employees, students, trainees, volunteers An offer is extended or a start date is set Every cycle
Medical Staff Office / Credentialing Practitioners and allied health professionals, employed or not, including locums and telehealth Appointment, privileges, or reappointment is granted Every cycle, plus each reappointment
Supply Chain / Purchasing Vendors, suppliers, and their personnel furnishing items or services A purchase order issues or a contract is signed or renewed Every cycle for active vendors
Billing / Revenue Cycle Practitioners billed under, billing and coding contractors The first claim is submitted Every cycle
Compliance Office The whole population, by reconciliation against payroll, the medical staff roster, and the vendor master Any gap is found Quarterly reconciliation

SourcesWhat each one catches that the others do not

SourceWhat it catches that the others do notCadence
OIG LEIEExclusion from all federal health care programs. The primary source, and the one OIG directs providers to useMonthly
SAM.gov exclusionsGovernment-wide debarment and suspension, a separate authority from exclusion, so a debarred entity may never appear on the LEIEMonthly
CMS Preclusion ListSeparate from OIG exclusion. Direct access is restricted; coordinate with the applicable Medicare Advantage or Part D plan and retain notices or screening evidence.Monthly coordination and on receipt of notices
State Medicaid exclusion listsPractitioners and entities a state has suspended or terminated who have not been federally excluded. See Exhibit B for what each state maintainsMonthly, every state you participate in
State licensing board disciplineBoard sanctions, suspensions, restrictions, and lapsed licenses, which typically precede any federal exclusion by months or yearsHire, credentialing, each renewal
NPDBMalpractice payments and adverse licensure, privileging, and professional society actions. Query rights are limited to eligible entitiesAppointment and reappointment
DEA registrationRegistration status, restrictions, and surrenders for prescribersHire and each renewal
FDA Debarment ListPersons debarred from working for or with drug and device firmsWhere drugs, devices, or research are handled
Why monthly. OIG advises monthly screening to reduce exclusion exposure. The monthly database-check duties in 42 CFR 455.436 apply to state Medicaid agencies; Practice duties also depend on state rules and contracts. This policy adopts monthly screening as a Practice control. Assess exposure using the exclusion effective date in the official record, not the posting or discovery date. Targeted correction: September 5, 2026.
Goulter Compliance Advisory · Exhibit A to Policy E08Draft for counsel review · not legal advice
Goulter Compliance AdvisoryHealthcare Privacy & Compliance
Exhibit A · Policy E08 · Page 2

Part 2: Potential match resolution worksheetOne sheet per name

Complete one worksheet for every potential match. A name is not cleared until the outcome line is filled in, so any worksheet left unfinished stays on the open items list until someone completes it. Do not take adverse action on an unverified name match.
Name as screenedExactly as it appeared on the roster
Roster it came fromPayroll, medical staff, vendor master
Source that produced the hit
Date screen was run
Date hit reviewed
Identifiers compared
Date of birth   Social Security number   NPI   License number   Address history   Other
Note which identifiers were available and which actually matched
Verification method used
OIG online search SSN verification   State list verification path   Direct contact with the issuing agency
First reviewer
Date
Second reviewerRequired unless cleared on identifiers alone
Date
Outcome
Not the same person, cleared   Confirmed match   Unresolved, escalated to the Compliance Officer
Action taken On a confirmed match: date removed from federal program work, date billing stopped, who was notified, whether counsel was engaged
Date closed
Where the supporting evidence is filed
Before you act on a match. Common names produce false positives, and taking adverse action on an unverified match creates its own liability. Confirm identity first. Where [Practice Name] uses a third-party background screening vendor that is a consumer reporting agency, coordinate the adverse action steps with counsel before acting. On a confirmed match, claims exposure is calculated from the exclusion effective date, not the date you discovered it.
Goulter Compliance Advisory · Exhibit A to Policy E08Retain completed worksheets for at least six years