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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-48. MEDICAID PROGRAM: REIMBURSEMENT |
Section 29-4823. NOTICE AND ADMINISTRATIVE REVIEW
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4823.1 All requests for administrative review shall be made in writing and delivered or emailed to the Department of Health care Finance, Reimbursement Analyst (Hospitals), Office of Rates, Reimbursement and Financial Analysis, 441 4th Street, NW, Suite 900 South, Washington, D.C. 20001, ORRFA-AdminReview@dc.gov. Upon completion of review or audit of annual cost reports (including rebasing years), DHCF shall provide the hospital with written notice of any audit adjustment(s) determined to apply to the hospital’s payment rates or cost to charge ratio (CCR).
4823.2 The notice issued from DHCF shall include the following, where applicable:
(a) A description of the audit or rate adjustment including an explanation, by appropriate reference to law, rules, State Plan Amendment, or program manual of the reason in support of the adjustment;
(b) The effective date of the adjustment or change in payment rate;
(c) A summary of all audit or payment rate adjustments made to reported costs, including an explanation, by appropriate reference to law, rules, or program manual, of the reasons in support of the adjustment; and
(d) An explanation of the right to request Administrative Review within sixty (60) calendar days after the date of the decision.
4823.3 Each hospital seeking Administrative Review, shall at minimum, provide the following information:
(a) The nature of the adjustment sought;
(b) The amount of the adjustment sought and the total dollar amount involved;
(c) The reasons or factors that the hospital believes justify an adjustment; and
(d) The documentation needed to support the hospital’s position, shall be subject to the following:
(1) A description of the total dollar amount involved shall be supported by generally accepted accounting principles; and
(2) A demonstration by the hospital that additional costs are necessary, proper and consistent with efficient and economical delivery of covered patient services.
4823.4 If changes are necessary as a result of the administrative review process, DHCF shall use the recalculated information to determine the rate for the period under review or make appropriate adjustments (for under-or overpayments) to the hospital’s payments during the period under review.
4823.5 DHCF shall issue a final written notice within one hundred twenty (120) calendar days after receipt of all requested additional documentation and/or information. The final notice shall include an explanation of the right to request an Administrative Hearing through the OAH within forty-five (45) calendar days of receipt of the final notice.
4823.6 The filing of an administrative appeal with the OAH shall not stay DHCF’s action to adjust a hospital’s payment rate or recover any overpayments made to the hospital.
4823.7 The methodologies in Sections 4800 through 4819 for all inpatient, including specialty, hospital services shall not be subject to Administrative Review or Appeal. This limitation on review and appeal shall include reimbursement methodology components that are national standards (e.g., relative weights), the District-wide Base Rate, and add-on payments.
4823.8 Hospitals shall not request Administrative Review of the reimbursement methodology for outpatient hospital services under 29 DCMR § 903, the Enhanced Ambulatory Patient Grouping (EAPG) base price, bundling techniques utilized under the EAPG methodology, or the national weights established under the EAPG reimbursement software.