D.C. Mun. Regs. tit. 29, r. 29-9401

Current through Register Vol. 72, No. 2, January 10, 2025

Rule 29-9401 - MEDICAID PROVIDER APPLICATION

9401.1

All provider applications shall be completed consistent with the requirements enumerated in § 9401.6 and submitted using the designated online application system, which may be accessed via www.dc-medicaid.com. Each provider shall complete and submit the application corresponding to the appropriate provider type and designated level of categorical risk assigned by DHCF.

9401.2

In accordance with 42 U.S.C. § 1320a-7k(e) and 42 C.F.R. § 431.107(b)(5), each provider shall obtain a National Provider Identification (NPI) number from the U.S. Department of Health and Human Services and include the NPI number on the application submitted to DHCF.

9401.3

Each out-of-District provider must include the following additional information in the application:

(a)The name, business address, and telephone number of its registered agent, in accordance with D.C. Official Code §§ 29-104.01et seq.:

(b)Proof of a physical business address and a business telephone number within the District listed under the name of the business for the purpose of providing Medicaid services and sales; and

(c)An active Medicare provider number, or a Medicaid provider number from the state in which the out-of-District provider’s principal place of business is located.

9401.4

A provider seeking enrollment as a provider of services for a Qualified Medicare Beneficiary (QMB) must be Medicare-certified and shall complete and submit the QMB provider application consistent with § 9401.1. A QMB provider shall only be paid for claims submitted for services or items covered by Medicare and delivered to a Medicare program enrollee.

9401.5

All provider applications must include a provider agreement signed with an approved electronic signature, in a manner consistent with the D.C. Uniform Electronic Transactions Act of 2001, as amended, effective October 3, 2001 (D.C. Law 14-28; D.C. Official Code §§ 28-4901 et seq.).

9401.6

A complete Medicaid provider application shall include:

(a) A provider agreement signed by the provider in accordance with the requirements of § 9401.5;

(b) Any relevant documents in accordance with the provider’s type, including proof that all required licensure is current; and

(c) All other required documents identified in the application.

9401.7

DHCF or its designated agent shall review each complete application within thirty (30) calendar days from the date of submission. If DHCF determines that a provider application is incomplete or contains incorrect information, it shall be returned to the provider for correction and resubmission, subject to the following limitations:

(a) A corrected application must be resubmitted to DHCF within sixty (60) calendar days of the date it was returned to the provider;

(b) DHCF shall allow resubmission of an application returned due to incomplete or incorrect information no more than twice within a twelve (12) month period; and

(c) If DHCF determines that the provider made a false representation or omission of any material fact in the original application, resubmission shall not be allowed.

9401.8

DHCF may deny an application if DHCF determines the provider has:

(a)Been convicted of a criminal offense that relates to the delivery of goods or services to a Medicaid beneficiary;

(b)Been convicted of any criminal offense that relates to a violation of fiduciary responsibility or financial misconduct

(c)Committed a violation of applicable federal, state, or District laws or regulations governing the Medicaid or Medicare programs

(d)Been excluded, suspended, or terminated from any program administered under Titles XVIII, XIX, and XXI of the Social Security Act;

(e)Been excluded, suspended, or terminated from any program managed by the District;

(f) Been previously found to have violated the standards or conditions of licensure, certification, or other professional standards;

(g)Made a false representation or omission of any material fact in making the application;

(h)Demonstrated an inability to provide services, conduct business, or operate a financially viable entity;

(i) Submitted an incorrect or incomplete application package to DHCF two (2) times in the past twelve (12) months;

(j) Owns or operates a setting which is subject to the requirements of 42 C.F.R. § 441.301(c)(4)and has failed to demonstrate compliance with the applicable requirements; or

(k)In accordance with the requirements set forth at 42 C.F.R. § 431.51and with concurrence from the Centers for Medicare and Medicaid Services (CMS) where needed, DHCF may deny an application based on the current availability of services, the need to ensure program integrity, or other reasonable standards

9401.9

Upon approval of an application, DHCF shall sign a provider agreement and send the provider a welcome letter that indicates the effective date of the signed provider agreement.

9401.10

The provider agreement shall be effective on the date it is signed by DHCF, except in the circumstances described at § 9401.11.

9401.11

In emergency circumstances, DHCF shall retain discretion to make the provider agreement retroactively effective to the date services were rendered. Emergency circumstances exist where a District Medicaid beneficiary is traveling outside the District when an emergency arises from an accident or illness and the health of the beneficiary would be endangered if:

(a) The beneficiary undertook travel to return to the District; or

(b) Medical care were postponed until the beneficiary returned to the District.

D.C. Mun. Regs. tit. 29, r. 29-9401

Final Rulemaking published at 60 DCR 10041 (July 12, 2013)

Authority: An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2006 Repl. & 2012 Supp.)) and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2008 Repl.)).