D.C. Mun. Regs. tit. 29, r. 29-5320

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

Rule 29-5320 - SANCTIONS FOR NON-COMPLIANCE

5320.1

If the Department determines that a prepaid, capitated provider has failed to comply with the provisions of this chapter or other applicable federal or District law or regulations, the Department may:

(a) Suspend further enrollment of Medicaid recipients by the prepaid, capitated provider;

(b) Withhold part of the organization's Medicaid payments;

(c) Use all or part of the deposit detailed in § 5303.2 and 5303.3; and

(d) Terminate the Medicaid managed care provider agreement within thirty (30) days from the date of notice of termination to the prepaid, capitated provider.

5320.2

Before taking any action described in § 5320.1, the Department shall provide written notice which shall include at least the following:

(a) A citation to the law or regulation that has been violated;

(b) The sanction to be applied and the date the sanction will be imposed;

(c) The basis for the Department's determination the sanction should be imposed; and,

(d) The time frame and procedure for the prepaid, capitated provider to appeal the Department's determination.

5320.3

A provider's appeal of action pursuant to § 5320.1(a) and (b) shall not stay the effective date of the proposed action.

5320.4

The Department shall provide reasonable written notice of a proposed sanction to AFDC and AFDC-related Medicaid recipients enrolled in the organization's managed care plan and others who may be affected by the proposed sanction. Notice to AFDC and AFDC-related Medicaid recipients shall be by first -class mail, postage prepaid, at the address reflected in the Department's records.

5320.5

Except as specifically provided in this section, 29 DCMR Chapter 13 shall apply to any administrative action taken with respect to a prepaid, capitated provider's participation in the program.

D.C. Mun. Regs. tit. 29, r. 29-5320

Final Rulemaking published at 42 DCR 1566, 1587 (March 31, 1995)