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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 29-94. MEDICAID PROVIDER AND SUPPLIER SCREENING, ENROLLMENT, AND TERMINATION |
Section 29-9403. MEDICAID PROVIDER OR SUPPLIER SCREENING
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9403.1Pursuant to 42 C.F.R. § 455.450, DHCF shall evaluate all Applications according to the level of categorical risk to which the provider or supplier type is assigned.
9403.2An Applicant shall be classified according to the following risk categories:
(a) High (subject to the screening requirements described in § 9404);
(b) Moderate (subject to the screening requirements described in § 9405); or
(c) Limited (subject to the screening requirements described in § 9406).
9403.3An Applicant that may reasonably fit within more than one (1) risk category shall be screened according to the highest level of screening that applies to that provider or supplier type.
9403.4DHCF shall adjust the categorical risk level from “Limited Risk” or “Moderate Risk” to “High Risk” under the following circumstances:
(a) The Applicant has been excluded by the Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services within the previous ten (10) year period;
(b) The Applicant has been excluded from another state’s Medicaid program within the previous ten (10) year period;
(c) DHCF or CMS lifted a temporary moratorium during the previous six (6) months for the specific provider or supplier type that an Applicant is applying under, and the Applicant applies within six (6) months from the date the moratorium was lifted;
(d) Medicare elevates the risk category for a particular provider type;
(e) DHCF imposes a payment suspension against a provider due to a credible allegation of fraud, waste, or abuse; or
(f) The provider has an existing Medicaid overpayment.
9403.5Providers or suppliers who are classified as “Moderate Risk” or “High Risk” shall be required to attend an orientation session before signing the Medicaid Provider Agreement.
9403.6DHCF shall reserve the right to modify screening requirements for any provider or supplier if DHCF determines Medicare or another state has successfully conducted a comparable screening on the same provider or supplier and that screening led to enrollment into Medicare or another Medicaid program.