D.C. Mun. Regs. tit. 29, r. 4209

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 4209 - REIMBURSEMENT: GENERAL

4209.1

DHCF shall not reimburse any provider of Waiver services who:

(a) Fails to comply with any applicable regulation in this chapter;

(b) Fails to comply with all applicable federal and District of Columbia laws, and regulations;

(c) Fails to comply with all applicable transmittals, rules, manuals and other requirements for payment issued by DHCF;

(d) Provides services in the absence of an approved prior authorization from DHCF or its designee for payment identifying the authorized service, number of hours or units authorized, duration, and scope of service; and

(e) Fails to comply with the terms of the Medicaid Provider Agreement.

4209.2

Each provider of Waiver services shall agree to accept as payment in full the amount determined by DHCF as reimbursement for the authorized waiver services provided to beneficiaries.

4209.3

Each provider shall agree to bill any and all known third-party payers prior to billing Medicaid.

4209.4

For purposes of this chapter, the effective dates of EPD Waiver Year Five (5) are January 4, 2016 through April 3, 2017.

4209.5

For purposes of this chapter, the effective dates of EPD Waiver Year One (1) of the Renewal are April 4, 2017 through January 3, 2018.

4209.6

In accordance with CMS' cost neutrality requirements, DHCF may limit or deny Waiver services if the cost of the services in addition to other home care services, exceeds the estimated cost of institutional care.

4209.7

Subsequent changes to any of the reimbursement rate(s) published herein shall be posted on the Medicaid fee schedule at www.dc-medicaid.com. DHCF shall also publish a notice in the D.C. Register which reflects the change in the reimbursement rate(s) at least thirty (30) days before a change is made to the reimbursement rate.

D.C. Mun. Regs. tit. 29, r. 4209

Final Rulemaking published at 64 DCR 6787 (7/21/2017)