6507.1 No person or entity shall apply for certification, and no transition planning provider shall apply for recertification or be permitted to maintain certification as a transition planning provider, if they are:
(a) Not enrolled in the District's Medicaid program, in accordance with the requirements of Title 29 Chapter 94, as a(n) : (1) Mental Health Rehabilitation Services (MHRS) provider;(2) Adult Substance Abuse Rehabilitative Services (ASARS) provider;(3) Free Standing Mental Health Clinic (FSMHC); or(4) Federally Qualified Health Center (FQHC); or(b) Subject to exclusion, suspension, termination, or sanction(s) as described in Title 29 DCMR Chapter 13 and Title 29 DCMM Chapter 94.6507.2 An applicant for initial certification as atransition planning provider shall demonstrate meeting, at the time of application submission, the following standards:
(a) Provides health home services pursuant to either Title 22-A DCMR Chapter 25 or Title 29 DCMR Chapter 69 or renders care coordination services;(b) Has at least three (3) years of experience providing mental health and/or SUD treatment services to a minimum of three hundred (300) individuals per calendar year in the DC metropolitan area;(c) Within the six (6) years prior to application submission, has assisted with the discharge of at least one hundred (100) individuals with complex needs from inpatient or residential mental health or SUD treatment settings, and achieved a thirty (30)-day readmission rate that does not exceed twenty percent (20%) for mental health or SUD-related admissions;(d) Within the six (6) months prior to application submission, for the population served by the applicant, the applicant rendered transition support, case management, or care coordination services to at least eighty percent (80%) of individuals who had inpatient or residential mental health or SUD treatment admissions; and(e) As evidenced by summary data from anytime within the previous three (3) calendar years, the ability to track and monitor:(1) The number of clients/consumers who have transitioned to a higher or lower level of care for treatment of a mental health or SUD diagnosis, including admissions to an inpatient or residential treatment setting; and(2) The responses to/outcomes of the inpatient or residential mental health or SUD treatment admissions.6507.3 A transition planning provider shall render the service to individuals in all three (3) populations described in § 6501.1(a), for whom the provider receives a referral. Circumstances in which a provider shall be exempt from the requirement to render the service are when:
(a) The referred individual does not consent to receive the transition planning service;(b) The referred individual is discharged from the institution or leaves the institution against medical advice, prior to the transition planning provider having initiated contact with the discharging institution in the time-frame specified in § 6507.4; or(c) Any other situation specified by the Department.6507.4 Upon notification of a referral, a transition planning provider shall contact the discharging institution in the following time- frame:
(a) If the provider is notified before 3:00 p.m., the provider shall contact the institution on the same day; and(b) If the provider is notified at 3:00 p.m. or after, the provider shall contact the institution by 10:00 a.m. the next day.6507.5 A transition planning provider shall respond to referrals and render services, as appropriate, seven (7) days per week, three hundred sixty- five (365) days per year. The provider shall at a minimum be available to respond to client/consumer and discharging entity communications during the hours of 8:15 a.m.-5:00 p.m. The provider shall respond on the same day if such communication was received before 3:00 p.m., or by 10:00 a.m. the next day if the communication was received at 3:00 p.m. or after.
6507.6 A transition planning provider shall operate according to all applicable Federal and District laws and regulations relating to fraud, waste, and abuse in health care and the Medicaid program. A provider's failure to report potential or suspected fraud, waste, or abuse may result in sanctions or exclusion from participation as a transition planning provider. Each transition planning provider shall:
(a) Cooperate and assist any District or Federal agency charged with the duty of identifying, investigating, or prosecuting suspected fraud, waste, or abuse;(b) Provide the Department with regular access to the provider's medical and billing records, including electronic medical records, within twenty- four (24) hours of a Departmental request, or immediately in the case of emergency;(c) Be responsible for promptly reporting suspected fraud, waste, or abuse to the Department, taking prompt corrective actions, and cooperating with DHCF or other governmental investigations; and(d) Ensure that none of its practitioners have been excluded from participation as a Medicaid or Medicare provider. If a practitioner is determined to be excluded by the Center for Medicare and Medicaid Services (CMS), the provider shall notify the Department immediately.6507.7 A transition planning provider shall comply with all Federal and District laws and regulations related to administrative practice ethics, including but not limited to, the False Claims Act, 31 U.S.C. §§ 3729-3733; the Anti-Kickback Statute, 42 U.S.C. § 1320a-7b; the Physician Self-Referral (Stark) Law, 42 U.S.C. § 1395nn; and the Exclusion Statute, 42 U.S.C. § 1320a-7.
6507.8 A transition planning provider shall have the necessary operational capacity to submit claims, document information on services provided, and track payments received with applicable Department and DHCF requirements.
6507.9 A transition planning provider shall participate through a formal agreement with a registered Health Information Exchange (HIE) entity of the DC Health Information Exchange (DC HIE), defined in Title 29 DCMR Chapter 87.
6507.10 A transition planning provider shall incorporate the service into the quality improvement and quality assurance policies and procedures required under its respective FSMHC, MHRS, or SUD provider certification, or the applicable Federal and District laws, regulations, and policies governing FQHCs.
6507.11 A transition planning provider shall incorporate the service into the liability insurance coverage required under its respective FSMHC, MHRS, or SUD provider certification, or the applicable Federal and District laws, regulations, and policies governing FQHCs.
6507.12 A transition planning provider shall follow the same corporate compliance and fiscal management standards and business record-keeping procedures as required under its respective FSMHC, MHRS, or SUD provider certification, or the applicable Federal and District laws, regulations, and policies governing FQHCs.
D.C. Mun. Regs. r. 22-A6507
Final Rulemaking published at 68 DCR 876 (1/15/2021)