Section 29-5214. AUDITS AND REVIEWS

 

5214.1MAA shall perform ongoing audits to ensure that Medicaid payments are consistent with efficiency, economy and quality of care, and made in accordance with federal and District rules governing Medicaid.

 

5214.2The audit process shall be conducted annually by MAA, to determine, by statistically valid scientific sampling, the appropriateness of services rendered and billed to Medicaid by DMH.

 

5214.3If MAA determines that claims are to be denied, MAA shall recoup, by the most expeditious means available, those monies erroneously paid to DMH for denied claims, following the period of Administrative Review set forth in subsection 5214.8 of these rules.

 

5214.4The recoupment amount for denied claims shall be determined by the following formula: A fraction shall be calculated with the numerator consisting of the number of denied claims from the audit sample. The denominator shall be the total number of paid claims from the audit sample. This fraction will be multiplied by the total dollars paid by Medicaid to DMH during the audit period, to determine the amount recouped. For example, if DMH received Medicaid reimbursement of ten thousand dollars ($ 10,000) during the audit period, and, during a review of the claims from the audited sample, it was determined that 10 claims out of 100 claims are denied, then ten percent (10%) of the amount reimbursed by Medicaid during the audit period, or one thousand dollars ($ 1000), would be recouped.

 

5214.5MAA shall issue a Notice of Recoupment (NR) to DMH, which sets forth the reasons for the recoupment, the amount to be recouped, and the procedures for requesting an Administrative Review.

 

5214.6DMH shall have sixty days from the date of the NR to submit a written request for Administrative Review of the NR. The request for Administrative Review of the NR shall be submitted to the Chief, Office of Program Integrity, Surveillance and Utilization Review Branch, Medical Assistance Administration, Department of Health.

 

5214.7The written request for Administrative Review shall include a description of the item to be reviewed, the reason for review of the item, the relief requested, and any documentation in support of the relief requested.

 

5214.8MAA shall mail a written determination relative to the Administrative Review not later than one hundred and twenty (120) days from the date of the written request for Administrative Review under 5214.6.

 

5214.9Within forty five (45) days of receipt of the MAA's written determination, DMH may appeal the written determination by filing a written notice of appeal with the Board of Appeals and Review.

 

5214.10Filing an appeal shall not stay any action to recover any overpayment.

 

source

Final Rulemaking published at 49 DCR 4860 (May 24, 2002).