126.1(a) Medical services, appliances, or supplies shall be billed and reimbursed at a rate that does not exceed the rate set forth on the medical fee schedule adopted by the Program.(b) For medical services, appliances, or supplies included on a Medicare fee schedule, the rate set forth on the Program's fee schedule shall be one hundred-thirteen percent (113%) of Medicare's reimbursement rates. For purposes of this chapter, medical supplies include medication and prescription drugs.(c) For medical services, appliances, or supplies not included on a Medicare fee schedule, the billing and reimbursement rate shall be the rate set forth for the services, appliances, or supplies on the Program's fee schedule published on the Healthcare Provider Information Page of the Office of Risk Management website.(d) If a medical service, appliance, or supply is not included on a Medicare fee schedule or the Program's published fee schedule, the billing and reimbursement rates shall be limited to the reasonable and customary charges prevailing in the local medical community, as determined by the Program.(e) Notwithstanding the foregoing, dispensing fees for prescription drugs shall not exceed five dollars ($5.00) per prescription filled.126.2 If a healthcare provider intends to bill for medical services, appliances, or supplies, where prior authorization is required, that provider must request or verify the existence of such prior authorization from the Program before providing services, appliances, or supplies. All medical bills submitted to the Program lacking required prior authorization will be automatically denied.
126.3 Unless otherwise authorized by the Program, all bills for medical services, appliances, or supplies rendered under the Act must be submitted on a CMS1500, Health Insurance Claim Form and shall:
(a) Include the code, as published by the American Medical Association (AMA) in the most current edition of the Current Procedural Terminology (CPT codes) for each care, supply, and service rendered and the codes established by the most recent edition of the International Classification of Diseases (ICD), as published by the U.S. Department of Health and Human Services, for diagnosing the claimant's condition. If there is no standard CPT code for a care, supply, or service rendered, the health care provider shall refer to the Program's fee schedule for the procedure code prescribed by the Program;(b) Include the "From" and "Through" dates with the appropriate units fo r each CPT code billed, when billing for care, supplies, or services over a period of time;(c) Include the name, address, telephone number, signature, and date of signature of the healthcare provider who rendered care, supplies, or services;(d) Be generated and submitted by the healthcare provider; and(e) Be supported by medical evidence documented on Form 3, 3S, 3RC, or other Program approved forms, as provided in § 125 of this chapter.126.4 The Program may withhold payment for an authorized service, appliance, or supply until a bill for such service, appliance, or supply is submitted in accordance with § 126.3 of this chapter.
126.5 A medical report or medical evidence that is not on a Program form submitted in support of a bill shall be typewritten on the healthcare provider's letterhead and signed and dated by the healthcare provider and include information required under § 125 of this chapter or as requested by the Program.
126.6 Unless otherwise authorized by the Program, all bills sha ll be submitted by first-class U.S. mail or electronically to the email address or fax number designated on the Healthcare Provider Information Page of the Office of Risk Management website.
126.7 No bill will be paid for expenses incurred if the bill is received more than one (1) year after the later of:
(a) The end of the calendar year in which the expense was incurred, or the medical service, appliance, or supply was provided; or(b) The end of the calendar year in which the claim was first accepted as compensable by the Program.126.8 Within thirty (30) days after receipt of a bill for medical services, appliances, or supplies submitted pursuant to the requirements of this section, the Program shall provide the claimant and healthcare provider with written notice approving, adjusting, denying, or disputing the bill.
126.9 If the Program fails to respond to a bill from a healthcare provider in accordance with this section and Section 2303(f) of the Act (D.C. Official Code § 1-623.03(f) ), the Program shall be deemed to have authorized payment of the bill, provided that the medical service, appliance, or supply is:
(a) For a condition that has been accepted as compensable by the Program; and(b) Prior authorization requirements are met.126.10 If the Program adjusts, denies, or disputes a bill, the Program shall issue a written Explanation of Review to the claimant and healthcare provider.
126.11 The Explanation of Review shall inform the recipients of the recipients' right to request a hearing before the Chief Risk Officer to dispute the Program's decision, unless the Program has:
(a) Initiated utilization review; or(b) Requested a hearing on the matter before the Chief Risk Officer.126.12 A request for a hearing before the Chief Risk Officer to dispute the Program's decision regarding the bill pursuant to Section 2323 (a-2)(4) of the Act (D.C. Official Code § 1-623.23 (a-2)(4)) shall be submitted by filing Form 9H with the Office of Risk Management no later than six (6) months of the later of:
(a) The date of the bill;(b) The date of initial payment of the bill; or(c) The date of the initial Explanation of Review.126.13 Prior to requesting a hearing before the Chief Risk Officer pursuant to § 126.12 of this chapter, a healthcare provider, but not a claimant, may seek reconsideration of the Program's adjustment, denial, or dispute of a bill as follows:
(a) For an Explanation of Review issued by the Program, complete and electronically submit Form 9R by email or fax to the email address or fax number designated on the Healthcare Provider Information Page of the Office of Risk Management website.(b) For an Explanation of Review prepared by a bill review vendor and issued by the Program, resubmit the bill directly to the vendor or contact the vendor directly to discuss the bill.126.14 A request for reconsideration does not toll the time to request a hearing as set forth in § 126.12 of this chapter.
126.15 Nothing in this section shall be construed to allow for payment of any medical service, appliance, or supply provided for a condition that is not accepted by the Program as being compensable under the Act.
Final Rulemaking published at 59 DCR 8766, 8796 (July 27, 2012); amended by Final Rulemaking published at 64 DCR 6325 (7/7/2017); amended by Final Rulemaking published at 66 DCR 4246 (4/5/2019)Authority: Chief Risk Officer of the Office of Risk Management (ORM), Executive Office of the Mayor, pursuant to the authority set forth in section 2344 of the District of Columbia Government Merit Personnel Act of 1978 (CMPA), effective March 3, 1979 (D.C. Law 2-139; D.C. Official Code § 1-623.44 (2012 Supp.)); section 7 of Reorganization Plan No. 1 of 2003 for the Office of Risk Management, effective December 15, 2003; and Mayor's Order 2004-198, effective December 14, 2004