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DEPARTMENT OF HEALTH CARE FINANCE
NOTICE OF FINAL RULEMAKING
The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in 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. 744; 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.)) hereby gives notice of the adoption, of an amendment to section 900 of chapter 9 (Medicaid Program) of title 29 (Public Welfare) of the District of Columbia Municipal Regulations (DCMR) entitled “Time Limitation on Payment of Medicaid Provider Claims.”
The purpose of these rules is to extend the timely filing period to promote compliance with State Plan requirements. A recent audit revealed that public providers were filing claims outside of the 180 day timely filing period established by the current State Plan. The effect of these emergency and proposed rules would increase the timely filing period from 180 to 365 days, the maximum allowed under federal regulations; clarify the calculation of the timely filing period when an initial claim is filed within the timely filing period but is denied and resubmitted subsequent to the end of the timely filing period; and clarify the calculation of the timely filing period for a Medicaid claim that is related to a claim for payment under Medicare that has been timely filed. The extended timely filing period would apply to all providers. In addition, these emergency and proposed rules would benefit an individual who has received service, but the Medicaid eligibility had to be determined retroactively.
The corresponding amendment to the District of Columbia State Plan for Medical Assistance (“State Plan”) was approved by the Council of the District of Columbia.(See, PR 19- 809, entitled, “Medicaid Timely Filing Approval Resolution of 2012”). A notice of emergency and proposed rules was published in the DC Register on September 21, 2012 (59 DCR 011007). No comments were received and no substantive comments have been made. The Director adopted these final rules on November 30, 2012. The September 21, 2012 notice included language indicating these rules would become effective for claims submitted on or after October 1, 2012, if the corresponding State Plan Amendment has been approved by U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) with an effective date of October 1, 2012, or the effective date established by CMS in its approval of the corresponding State Plan Amendment, whichever is later. By letter dated October 24, 2012, CMS approved the State Plan amendment with an effective date of October 1, 2012. These rules shall become effective upon publication of this notice in the DC Register.
Section 900 (Time Limitation on Payment of Medicaid Provider Claims) of chapter 9 (Medicaid Program) of title 29 (Public Welfare) of the DCMR is deleted in its entirety, and replaced with the following:
900 TIME LIMITATION ON PAYMENT OF MEDICAID PROVIDER CLAIMS
900.1 A claim for Medicaid reimbursable services may be submitted electronically or on paper by the enrolled billing provider.
900.2 Effective October 1, 2012, the Department of Health Care Finance (DHCF) shall not pay any claim submitted with a date of service that is greater than three hundred and sixty-five (365) days prior to the date of submission. All claims for services submitted after three hundred and sixty-five days (365) from the date of service shall be ineligible for payment.
900.3 For an individual whose eligibility has been determined retroactively, the timely filing period begins on the date of the eligibility determination.
900.4 Where an initial claim is submitted within the timely filing period but is denied and resubmitted subsequent to the end of the timely filing period, the resubmitted claim shall be considered timely filed provided it is received within three hundred and sixty-five (365) days of the denial of the initial claim.
900.5 If a claim for payment under Medicare has been filed in a timely manner, DHCF may pay a Medicaid claim relating to the same services within one hundred and eighty (180) days after DHCF or the provider receives notice of the disposition of the Medicare claim.
900.6 The date of submission shall be the date the agency receives the claim, as defined by the Transactional Control Number (TCN) assigned to each claim.
900.7 The provisions in this Chapter shall apply to all providers who submit claims to DHCF for adjudication.
Section 999 (Definitions) is amended by adding the following definition in alphabetical order:
Claim - A claim is a submission requesting payment for specific services rendered to a recipient
by the Billing provider.
