Section 29-1303. NOTICE OF PROPOSED EXCLUSION OR TERMINATION

 

1303.1If the Director proposes to deny reimbursement to a provider under §1301 or to terminate a provider agreement pursuant to §1302, he or she shall send written notice of intent and the reasons for the proposed exclusion or termination to the provider. The notice shall include the following:

 

(a)The basis for the proposed action;

 

(b)The specific action the Director intends to take;

 

(c)The provider's right to dispute the allegations and to submit evidence to support his or her position; and

 

(d)Specific reference to the particular sections of the statutes, rules, provider's manual, and/or provider's agreement involved.

 

1303.2Within thirty (30) days of the date on the notice, the provider may submit documentary evidence and written argument against the proposed action.

 

1303.3For good cause shown, the Director may extend the thirty (30) day period prescribed in §1303.2.

 

1303.4If the Director decides to exclude the provider under §1301 or terminate the provider agreement under §1302 after the provider has filed a response under §1303.2, then the Director shall send written notice of his or her decision to the affected party at least fifteen (15) days before the decision becomes effective. The notice shall include the following:

 

(a)The reasons for the decisions;

 

(b)The effective date of the termination or exclusion;

 

(c)The extent of the applicability to participation in the District's Medicaid Program;

 

(d)The earliest date on which the Director shall accept a request for reinstatement determined in accordance with §1315.2;

 

(e)The requirements and procedures for reinstatement in the District's Medicaid Program; and

 

(f)The provider's right to request a hearing by filing a notice of appeal with the D.C. Board of Appeals and Review.

 

1303.5If the provider files a notice of appeal within fifteen (15) days of the date of the notice of termination or exclusion, then the effective date of the proposed action shall be stayed pending a decision following final action by the D.C. Board of Appeals and Review.

 

1303.6Except as provided in §1303.8 and §1303.9, a provider who has been excluded or terminated from the District's Medicaid Program shall be precluded from submitting any claims for payment, either personally or through claims submitted by any clinic, group, corporation or other association, for any health care provided under the Medicaid Program after the effective date of the exclusion or termination.

 

1303.7If the provider has been excluded or terminated from participation in the Medicare Program or otherwise sanctioned because of fraud or abuse under that program, the effective date of denial of payment for services or termination from the District's Medicaid Program shall be the effective date of exclusion from the Medicare Program as established by HCFA.

 

1303.8Medicaid payments shall be made for inpatient services furnished in a hospital, skilled nursing facility or intermediate care facility to a recipient who was admitted before the effective date of the Medicare exclusion for up to thirty (30) days after the date of the Medicare exclusion.

 

1303.9Payment for home health services furnished under a plan established before the effective date of the exclusion shall be available to the extent federal financial participation is available under the federal regulation.

 

source

Final Rulemaking published at 31 DCR 3870 (August 3, 1984).