Section 29-9203. CLAIMS RECOUPMENT OR RECONCILIATION

9203.1For those beneficiaries dually-eligible for Medicare and Medicaid, the District’s Medicaid PPC payment adjustment policy shall also apply to those claims denied under Medicare’s preventable conditions policy.

9203.2 A Medicaid provider shall be subject to reimbursement recoupment or  reconciliation based on the Medicaid Provider Preventable Conditions Payment Adjustment Policy. A determination of overpayments and/or underpayments shall be based on one (1) or more of the following factors:

(a) Whether the procedure or diagnosis underlying the claim is a PPC;

(b) Whether the condition results in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis;

(c) Whether the claim resulting from the service was priced correctly;

(d) Whether the provider properly coded the claim by using the present on admission (POA) indicator field; and

(e) Whether the claim duplicates a previously paid claim. 

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).