Section 29-1309. PROCEDURES REGARDING DETERMINATION OF PROGRAM REIMBURSEMENT BASED UPON COST REPORTS

 

1309.1The procedures contained in this section through §1311 govern DHS determinations of Medicaid program reimbursement due to those Medicaid providers who are reimbursed based upon cost reports filed by the providers.

 

1309.2Upon receipt of a provider's cost report, the Director shall, within a reasonable period of time, analyze the report and furnish the provider a written notice reflecting the determination of the amount of program reimbursement due to the provider. The notice shall include the following:

 

(a)Explain the Department's determination of total program reimbursement due the provider for the reporting period covered by the cost report or amended report;

 

(b)Relate this determination to the provider's claimed total program reimbursement due for the reporting period;

 

(c)Explain the amount of the program reimbursement;

 

(d)Explain the reason why, by appropriate reference to law, regulations, or program manual, the determination differs from the provider's claim; and

 

(e)Inform the provider of his or her right to a hearing and that the hearing shall be requested within thirty (30) days after the date of notice.

 

1309.3The determination, as contained in a notice of amount of program reimbursement, shall constitute a basis for making the retroactive adjustments to any program payments made to the provider during the period to which the determination applies.

 

1309.4The determination shall also include the suspension of further payments, in whole or in part, to the provider in order to recover or to aid in the recovery of any overpayments identified in the determination to have been made to the provider, notwithstanding any request for a hearing on the determination the provider may make.

 

1309.5The suspension shall remain in effect as specified in §1308 of this chapter.

 

source

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