D.C. Mun. Regs. tit. 29, r. 4256

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

Rule 4256 - APPEAL RIGHTS FOR PROVIDERS AGAINST WHOM A RECOUPMENT IS MADE

4256.1

The provider shall have thirty (30) cale ndar days from the date of the NPRMO to respond in writing. The response shall be submitted to the DHCF's Director of the Division of Program Integrity.

4256.2

The provider's written response to the NPRMO shall include a specific description of the item(s) to be reviewed, the reason for the request for review, the relief requested, and documentary evidence in support of the relief requested.

4256.3

The DHCF's Division of Program Integrity shall mail a written determination no later than one hundred and twenty (120) calendar days from the date of receipt of the provider's response to the NPRMO.

4256.4

Payments otherwise authorized to be made to a provider under the District of Columbia Medicaid Program may be suspended or recouped, in whole or in part, by DHCF to recover or aid in the recovery of overpayments that have been made to the provider.

4256.5

The DHCF shall notify the provider of its intention to recoup payments, in whole or in part, and the reasons for the recoupment in a Final Notice of Medicaid Overpayment Recovery (FNPRMO). The Final Notice to providers shall include the following:

(a) The factual basis for the determination of overpayments including the dollar value of the overpayment;

(b) How the overpayment was computed;

(c) Specific reference to the section of the statute, rule, provider's manual, or provider agreement that is the basis for the recoupment; and

(d) Information about the government entity who checks shall be made payable to and the corresponding mailing address.

4256.6

Any provider that disagrees with the reason for a recoupment or the amount of the recoupment shall have fifteen (15) calendar days from the date of the FNPRMO to request a hearing by filing an appeal with the District of Columbia Office of Administrative Hearings (OAH).

4256.7

Filing an appeal with the OAH shall not stay any action to recover any overpayment to the provider. The provider shall be liable to the Medicaid Program for any overpayments as set forth in the FNPRMO.

4256.8

The provider shall file a written Notice of Appeal with the Office of Administrative Hearings , 441 4th Street, NW, Suite 450 North, Washington, D.C. 20001. The provider shall also send a copy of that Notice of Appeal to the DHCF Office of General Counsel.

D.C. Mun. Regs. tit. 29, r. 4256

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