D.C. Mun. Regs. tit. 29, r. 29-4519

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

Rule 29-4519 - APPEALS

4519.1

For appeals of DHCF Payment Rate Calculations, Scope of Service Adjustments or Audit Adjustments for FQHCs the following applies:

(a) At the conclusion of any required audit, payment rate or scope of service adjustment, the FQHC shall receive a notice that includes a description of each audit finding, payment rate or scope of service adjustment and the reason for any adjustment to allowable costs or to the payment rate;

(b) An FQHC may request an administrative review of payment rate calculations, scope of service adjustments or audit adjustments. The FQHC may request administrative review within thirty (30) calendar days of receiving the Notice of Audit Findings by sending a written request for administrative review to the Office of Rates, Reimbursement and Financial Analysis, DHCF;

(c) The written request for administrative review shall identify the specific audit adjustment, payment rate calculation, or scope of service adjustment to be reviewed, and include an explanation of why the FQHC believes the adjustment or calculation to be in error, the requested relief, and supporting documentation;

(d) DHCF shall mail a formal response to the FQHC no later than sixty (60) calendar days from the date of receipt of the written request for administrative review;

(e) Within thirty (30) calendar days of receipt of DHCF's written determination relative to the administrative review, the FQHC may appeal the determination by filing a written request for appeal with the Office of Administrative Hearings (OAH);

(f) The filing of an appeal with OAH shall not stay DHCF's action to adjust the FQHCs payment rate;

(g) Resolution of payment rate, scope of service adjustment, or audit adjustment in favor of an FQHC shall be applied consistent with the process as described below:

(1) The resolution of audit findings in favor of an FQHC will be applied retroactively to the date the initial adjustment was to have taken effect;

(2) The resolution of scope of service adjustments in favor of an FQHC shall be prospective only, beginning the first day of the month following resolution of the scope of services adjustment ; and

(3) The resolution of payment rate adjustments shall be retroactive to the date when DHCF received a completed request for administrative review.

4519.2

For FQHC appeals of DHCF decisions on fee- for-service claims the following applies:

(a) An FQHC may request a formal review of a decision made on a fee- for-service claim. To be eligible for a formal review, the FQHC must make the request within three- hundred and sixty- five (365) calendar days of receiving notice of the decision;

(b) The written request for formal review shall include an explanation of the problem, the requested relief, supporting documentation and meet any additional standards DHCF or its designee may require. Written requests for formal review must be sent to the addresses provided in the DC MMIS Provider Billing Manual;

(c) DHCF or its designee shall render a written decision on a request for a formal review within forty-five (45) calendar days of a completed request for review; and

(d) Nothing in this rule waives or modifies the requirements for the timely filing of Medicaid provider claims set forth in 29 DCMR §§ 900, et seq.

4519.3

For FQHC appeals of MCO decisions on claims for reimbursement the following applies:

(a) Effective July 1, 2017, for dates of services after April 1, 2017, an FQHC may request administrative reconsideration from DHCF in order to challenge an MCO's denial, nonpayment or underpayment of a claim. To be eligible for administrative reconsideration, the FQHC shall:

(1) Exhaust the MCO appeal process for the MCO that issued the denial, nonpayment or underpayment; and

(2) Receive a final written notice of determination (WND) from the MCO, or provide documentation that the timeframe for the MCO to render a final WND has expired without decision; and

(b) Requests for administrative reconsideration shall be made to DHCF by mail, email, fax, or in person to DHCF's Appeals Coordinator within thirty (30) calendar days of the date of the final WND from the MCO. If no final WND was provided, the request shall be made within thirty (30) calendar days of the date that the MCO was due to render its final WND. Requests for administrative reconsideration shall include the following minimum information and documentation:

(1) MCO name;

(2) MCO ID;

(3) A copy of the final WND indicating that the FQHC has exhausted all available appeal opportunities with the MCO, or documentation indicating the deadline for the MCO to render a final WND has expired;

(4) An original fee-for-service equivalent claim for reimbursement which shall include:

(i) Date of Service;

(ii) Healthcare Common Procedure Coding System/Current Procedural Terminology code;

(iii) Payment amount at issue;

(iv) Medicaid ID of the enrollee; and

(v) Name and Date of Birth of enrollee; and

(5) A written statement by the FQHC describing why the MCO's decision should not be upheld, including any supporting documentation; and

(c) DHCF will notify the MCO when a FQHC request for administrative reconsideration has been filed to allow the MCO the opportunity to share supporting documentation;

(d) DHCF reserves the right to request additional information and/or supporting documentation from the FQHC and/or the MCO, as appropriate, to assist in its determination. Failure to respond to agency requests for additional information and/or supporting documentation within the timeframe provided will not prevent DHCF from rendering a written decision;

(e) DHCF shall render a written decision within forty- five (45) calendar days of receiving a complete request for administrative reconsideration. If new information is provided to DHCF that warrants an extension in the amount of time it will take the agency to render a decision, the agency reserves the right to extend its review period by no more than ten (10) calendar days. The FQHC shall be notified if such an extension is required;

(f) The written decision shall constitute the final determination on the subject claim. The written decision by DHCF shall include the following minimum information:

(1) Basis for decision; and

(2) Supporting documentation or findings, if appropriate; and

(g) If DHCF determines that the decision of the MCO was improper, then DHCF will direct the MCO to make proper payment to the provider no later than thirty (30) calendar days of its written decision. Once payment is made, the FQHC can follow protocol in making a request to DHCF for wrap payment;

(h) If DHCF determines that the decision of the MCO was proper, but that the FQHC is still due reimbursement or payment, DHCF shall make the appropriate payment no later than thirty (30) calendar days of its written decision;

(i) If DHCF determines that the decision of the MCO was proper and the FQHC is not due reimbursement or payment, DHCF shall deny reimbursement; and

(j) Nothing in this rule waives or modifies the requirements for the timely filing of Medicaid provider claims set forth in 29 DCMR §§ 900, et seq.

D.C. Mun. Regs. tit. 29, r. 29-4519

Final Rulemaking published at 64 DCR 907 (2/2/2018)