D.C. Mun. Regs. tit. 29, r. 29-9403

Current through Register Vol. 71, No. 43, October 25, 2024

Rule 29-9403 - MEDICAID PROVIDER OR SUPPLIER SCREENING

9403.1

Pursuant to 42 C.F.R. § 455.450, DHCF shall evaluate all Applications according to the level of categorical risk to which the provider or supplier type is assigned.

9403.2

An Applicant shall be classified according to the following risk categories:

(a) High (subject to the screening requirements described in § 9404);

(b) Moderate (subject to the screening requirements described in § 9405); or

(c) Limited (subject to the screening requirements described in § 9406).

9403.3

An Applicant that may reasonably fit within more than one (1) risk category shall be screened according to the highest level of screening that applies to that provider or supplier type.

9403.4

DHCF shall adjust the categorical risk level from "Limited Risk" or "Moderate Risk" to "High Risk" under the following circumstances:

(a) The Applicant has been excluded by the Office of Inspector General ("OIG") of the U.S. Department of Health and Human Services within the previous ten (10) year period;

(b) The Applicant has been excluded from another state's Medicaid program within the previous ten (10) year period;

(c) DHCF or CMS lifted a temporary moratorium during the previous six (6) months for the specific provider or supplier type that an Applicant is applying under, and the Applicant applies within six (6) months from the date the moratorium was lifted;

(d) Medicare elevates the risk category for a particular provider type;

(e) DHCF imposes a payment suspension against a provider due to a credible allegation of fraud, waste, or abuse; or

(f) The provider has an existing Medicaid overpayment.

9403.5

Providers or suppliers who are classified as "Moderate Risk" or "High Risk" shall be required to attend an orientation session before signing the Medicaid Provider Agreement.

9403.6

DHCF shall reserve the right to modify screening requirements for any provider or supplier if DHCF determines Medicare or another state has successfully conducted a comparable screening on the same provider or supplier and that screening led to enrollment into Medicare or another Medicaid program.

D.C. Mun. Regs. tit. 29, r. 29-9403

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.)).