Section 29-4237. SPECIFIC PROVIDER REQUIREMENTS:ASSISTED LIVING

 

4237.1The provider shall have sixty (60) days from the date of the Notice of Recoupment (NR) to request, in writing, an Administrative Review of the NR. The request for administrative review shall be submitted to the Chief, Office of Program Integrity, Medical Assistance Administration, D.C. Department of Health.

 

4237.2The written request for Administrative Review shall include a specific description of the item to be reviewed, the reason for the request for review, the relief requested, and documentation in support of the relief requested.

 

4237.3The MAA shall mail a written determination relative to the Administrative Review to the provider no later than one hundred and twenty (120) days from the date of the written request for Administrative Review.

 

4237.4Filing an appeal with the Board of Appeals and Review shall not stay any action to recover any overpayment to the provider. The provider shall be liable to the Medicaid Program for any overpayments as set forth in the Medicaid Program determination.

 

4237.5Payments otherwise authorized to be made to a provider under the District of Columbia Medicaid Program may be suspended, in whole or in part, by MAA to recover or aid in the recovery of overpayments that have been made to the provider.

 

4237.6The MAA shall notify the provider of its intention to suspend payments, in whole or in part, and the reasons for making the suspension. The notice to providers shall include the following:

 

(a)The factual basis for the determination of overpayments including the dollar value of the overpayment;

 

(b)How the overpayment was computed; and

 

(c)Specific reference to the section of the statute, rule, provider's manual, or provider agreement that is the basis for the recoupment.

 

4237.7Any provider that disagrees with the reason for a recoupment or the amount of the recoupment shall have sixty (60) days from the date of the Notice of Recoupment to submit a written request for Administrative Review to the Chief, Office of Program Integrity, Medical Assistance Administration, D.C. Department of Health.

 

4237.8The written request for Administrative Review shall include a specific description of the item to be reviewed, the reason for the request for review, the relief requested, and documentation in support of the relief requested.

 

4237.9Within forty-five (45) days of receipt of the Medicaid Program's written determination, the provider may appeal the written determination by filing a written Notice of Appeal with the Board of Appeals and Review, 441 4th Street, NW, Suite 540, Washington, D.C. 20001.

 

source

Final Rulemaking published at 50 DCR 9025 (October 24, 2003).