Section 29-5414. SANCTIONS FOR NON-COMPLIANCE

 

5414.1If the Department determines that a fee-for-service primary care provider has failed to comply with the provisions of this chapter or other applicable federal or District law or regulations, the Department may:

 

(a)Suspend further enrollment of Medicaid recipients by the provider;

 

(b)Withhold part of the provider’s Medicaid payments; and

 

(c)Terminate the Medicaid managed care provider agreement within thirty (30) days from the date of notice of termination to the provider.

 

5414.2Before taking any action described in §5414.1, the Department shall provide written notice of the failure to comply to fee-for-service primary care provider, which shall include at least the following:

 

(a)A citation to the law or regulation at issue;

 

(b)The sanction to be applied and the date the sanction will be applied;

 

(c)The basis for the Department’s determination that the sanction should be imposed; and

 

(d)The time frame and procedure for the fee-for-service primary care provider to appeal the Department’s determination.

 

5414.3A provider’s appeal of action pursuant to §5314.1(a) and (b) shall not stay the effective date of the proposed action.

 

5414.4The Department shall provide reasonable written notice of a proposed sanction to AFDC and AFDC-related Medicaid recipients enrolled with the fee-for-service primary care provider and others who may be affected by the proposed sanction. Notice to AFDC and AFDC-related Medicaid recipients shall be by first-class mail, postage prepaid, at the address reflected in the Department’s records.

 

5414.5Except as specifically provided in this section, 29 DCMR Chapter 13 shall apply to any administrative action taken with respect to a fee-for-service primary care provider’s participation in the program.

 

source

Final Rulemaking published at 42 DCR 1566, 1595 (March 31, 1995).