D.C. Mun. Regs. tit. 29, r. 29-10210
DHCF shall perform audits of My Health GPS entities to ensure that Medicaid payments for My Health GPS services are consistent with efficiency, economy and quality of care, and made in accordance with federal and District conditions of payment.
DHCF audits of My Health GPS entities shall be conducted when necessary to investigate and maintain program integrity.
DHCF shall perform audits of claims submitted by My Health GPS entities, including using statistically valid scientific sampling, to determine the appropriateness of My Health GPS services rendered and billed to Medicaid to ensure that Medicaid payments can be substantiated by documentation that meets the requirements set forth in § 10207.18 and are made in accordance with all requirements of this chapter and all other applicable federal and District laws.
If DHCF determines that any claim(s) submitted by a My Health GPS entity were not submitted in accordance with all requirements of this Chapter and all other applicable federal and District laws, DHCF shall deny the identified claim(s) and recoup those monies erroneously paid to a My Health GPS entity following the period of Administrative Review, as set forth in § 10210.6.
If DHCF recoups monies erroneously paid to a My Health GPS entity for denied claims, DHCF shall issue a Proposed Notice of Medicaid Overpayment Recovery (PNR) to the My Health GPS entity, which sets forth the reasons for the recoupment, the amount to be recouped, and the procedures and timeframes for requesting an Administrative Review of the PNR.
The My Health GPS entity shall have thirty (30) calendar days from the date of the PNR to request an Administrative Review, which may be extended for good cause. The My Health GPS entity may submit documentary evidence and written argument against the proposed action to DHCF in the request for an Administrative Review. If the My Health GPS entity fails to respond to the PNR within thirty (30) calendar days or by the extended deadline if good cause has been granted, DHCF shall issue a Final Notice of Medicaid Overpayment Recovery (FNR), which shall include the procedures and timeframes for requesting an appeal.
DHCF shall review the documentary evidence and written argument submitted by the My Health GPS entity against the proposed action described in the PNR. After this review, DHCF may cancel its proposed action, amend the reasons for the proposed recoupment and adjust the amount to be recouped. DHCF shall then issue a FNR, which shall include the procedures and timeframes for requesting an appeal.
The My Health GPS entity may appeal the FNR by filing a written hearing request with the Office of Administrative Hearings within fifteen (15) calendar days from the date of the FNR. The written notice requesting an appeal shall inc lude a copy of the FNR, description of the item to be reviewed, the reason for review of the item, the relief requested, and any documentation in support of the relief requested.
Filing an appeal shall not stay any action to recover any overpayment.
In lieu of the off-set of future Medicaid payments, the My Health GPS entity may choose to send a certified check made payable to the District of Columbia Treasurer in the amount of the funds to be recouped within thirty (30) calendar days following the period of Administrative Review as set forth in § 10210.6.
Each My Health GPS entity shall allow access to all relevant records and program documentation during an on-site audit or review to DHCF, its designee, other authorized District of Columbia government officials, the Centers for Medicare and Medicaid Services (CMS), and representatives of the United States Department of Health and Human Services.
Each My Health GPS entity shall facilitate audits and reviews by maintaining the required records and by cooperating with the authorized personnel assigned to perform audits and reviews.
D.C. Mun. Regs. tit. 29, r. 29-10210