Section 29-9200. GENERAL PROVISIONS

 

9200.1The purpose of this chapter is to establish limitations for reimbursement by the Medicaid program for provider preventable conditions. These rules shall:

(a)Identify Provider Preventable Conditions (PPCs) which shall be included in the Department of Health Care Finance (DHCF) payment adjustment policy;

(b)Identify providers subject to the DHCF’s PPC payment adjustment policy; and

(c)     Establish procedures for providers to self-report the occurrence of PPCs in their claims systems.

9200.2Subject to the requirements set forth in Section 2702 of the Patient Protection and Affordable Care Act of 2010 (the Act), approved March 23, 2010 (Pub. L. No. 111-148; 124 Stat. 119; 42 C.F.R. §§ 434, 438, and 447), the DHCF’s PPCs payment adjustment policy shall include all of the PPCs included in Medicare’s inpatient hospital payment adjustment regulations and any subsequent updates or revisions promulgated under section 1886(d)(4)(D) of the Social Security Act (42 U.S.C. § 1395ww).

9200.3The list of PPCs which are subject to payment adjustments by the DHCF under the District of Columbia’s Medicaid program shall include Health Care Acquired Conditions (HCACs) and Other Provider Preventable Conditions (OPPC). 

 

9200.4DHCF’s PPC payment adjustment policy shall apply to all hospital claims for dates of discharge on or after July 1, 2012.

9200.5For non-hospital providers, the payment adjustment policy shall apply to all claims for services rendered on or after July 1, 2012.

9200.6DHCF’s PPC payment adjustment policy shall also apply to the terms of the contracts entered into by Managed Care Organizations (MCOs) and the District of Columbia.  The MCO’s payment policies must comply with the DHCF’s PPC payment adjustment policy.  MCOs must ensure that their payment policies prohibit reimbursement to its providers for any amount expended when providing medical assistance for PPCs.

 

authority

An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 774; D.C. Official Code § 1-307.02(2006 Repl. & 2012 Supp.) and section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2008 Repl.)).

source

Final Rulemaking published at 59 DCR 14960 (December 21, 2012).