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

Current through Register 71, No. 45, November 7, 2024

Rule 29-9401 - MEDICAID PROVIDER/SUPPLIER APPLICATION

9401.1

An Applicant shall submit a completed Application to DHCF, or its designee. The Application shall correspond to the appropriate category of provider and designated level of risk that DHCF assigns to the provider type.

9401.2

In accordance with Section 1128 J- of the Social Security Act ( 42 U.S.C. § 1320a - 7k(e)) and 42 C.F.R. § 431.107(b)(5), each Applicant shall obtain a National Provider Identification (NPI) number from the U.S. Department of Health and Human Services and ensure the NPI is provided on the Application submitted to DHCF.

9401.3

In addition to the Application, an out-of-District Applicant shall also submit the following, if applicable to the Applicant's corporate structure:

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

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

(c) The Medicaid provider number, supplier numbers from the state where the out-of-state business' principal place of business is located and/or the active Medicare supplier number.

9401.4

DHCF shall review an Applicant's signed and finished Application within thirty (30) business days from the date it was received by DHCF. DHCF shall return a provider application package to the Applicant when DHCF determines the provider application package to be incomplete or to contain incorrect information. DHCF shall allow resubmission for incomplete or incorrect information a maximum of two (2) times within the same twelve (12) month period.

9401.5

DHCF may deny an Application through the screening process if DHCF determines that an Applicant has any of the following:

(a) A conviction for a criminal offense that relates to the delivery of goods or services to a Medicaid beneficiary;

(b) A conviction for 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 Medicaid 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 of Columbia;

(f) Been previously found by a licensing, certifying, or professional standards board to have violated the standards or conditions relating to licensure or certification of the services provided;

(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; or

(i) Has had a provider application package returned by DHCF three (3) times in the past twelve (12) months due to incomplete or incorrect information.

9401.6

DHCF may deny an Application based on the current availability of services or supplies for beneficiaries taking into account geographic location and reasonable travel time and the number of providers of the same type of service or supplies enrolled in the same geographic area.

9401.7

DHCF shall deny an Application in accordance with § 9410.1.

9401.8

For a first-time Applicant to be a District Medicaid Provider, if the Application is denied, the Applicant shall not submit a new Application to DHCF sooner than one (1) year after the date that DHCF notified the Applicant of the denial.

9401.9

For an Applicant subject to revalidation, if the Application is denied, the Applicant shall not submit a new Application to DHCF sooner than two (2) years after the date that DHCF notified the applicant of the denial.

9401.10

The Application shall not be considered to be a Provider Agreement.

9401.11

The Provider Agreement shall be signed by the Director, or a designee. Upon approval of the Application, DHCF shall send the Applicant a welcome letter that shall indicate the effective date of the Provider Agreement.

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.)).