Section 29-1314. REINSTATEMENT TIMING AND METHOD OF REQUEST FOR REINSTATEMENT

 

1314.1This section governs requests for reinstatement in the District's Medicaid Program that are submitted by any one (1) of the following:

 

(a)A party who has been excluded from the program for fraud and/or abuse;

 

(b)A party suspended from participation for conviction of program-related crimes; or

 

(c)A party terminated from the program.

 

1314.2In order to establish the earliest date upon which the Director may consider a request for reinstatement of a party who has been excluded from participation in the program, the Director shall consider the following:

 

(a)The number and nature of the program violations and other related offenses;

 

(b)The nature and extent of any adverse impact the violations have had on recipients;

 

(c)The amount of any damages;

 

(d)Whether there are any mitigating circumstances; and

 

(e)Any other facts bearing on the nature and seriousness of the program violations or related offenses.

 

1314.3A party may request reinstatement in the District's Medicaid Program by filing a request in writing, with the Director, after the date specified in the notice of exclusion or suspension setting forth reasons why he or she should be reinstated.

 

1314.4The person shall submit or authorize the Director to obtain the following items:

 

(a)Statements from peer review bodies, probation officers, where appropriate, or professional associates as required by the Director, attesting to their belief and supported by facts, that the violations which led to the exclusion or conviction shall not be repeated; and

 

(b)Statements from private health insurers indicating whether there have been any questionable claims submitted during the period of exclusion or suspension.

 

1314.5The Director shall not reinstate a party that has been suspended from Medicare or suspended at the direction of HCFA or until HCFA notifies the Director that the party may be reinstated.

 

1314.6If HCFA notifies the Director that it has reinstated a party under Medicare, the Director shall automatically reinstate the party in the District's Medicaid Program, effective on the date of reinstatement under Medicare, unless the Director has imposed an administrative sanction against the party under these rules.

 

1314.7When a provider agreement has been terminated in accordance with this chapter, the Director shall not accept a new agreement from that party unless the following conditions are met:

 

(a)The Director finds that the reason for termination of the previous agreement has been removed and there is reasonable assurance that it will not recur; and

 

(b)The Director finds that the party has fulfilled, or has made satisfactory arrangements to fulfill, all of the statutory and regulatory responsibilities of its previous agreement.

 

source

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