D.C. Mun. Regs. tit. 29, r. 29-9300

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

Rule 29-9300 - GENERAL PROVISIONS

9300.1

In accordance with the requirements set forth in § 1902(a)(42)(B)(i) of the Social Security Act (the Act), ( 42 U.S.C. § 1396 a(a)(42)(B)(i)), and 42 C.F.R. §§ 455.500et seq., the Department of Health Care Finance (DHCF) shall establish the Medicaid Recovery Audit Contractor (Medicaid RAC) Program.

9300.2

The Medicaid RAC Program shall support program integrity efforts by identifying overpayments and underpayments, and fraudulent and abusive claims activity.

9300.3

Subject to the requirements set forth in the Procurement Practices Reform Act of 2010, effective April 8, 2011 (D.C. Law 18-371; D.C. Official Code §§ 2-351.01, et seq. (2012 Repl.)), DHCF shall contract with one (1) entity that shall be the Medicaid RAC pursuant to 42 C.F.R. §§ 455.500 - 455.518.

9300.4

The contracted entity identified in § 9300.3 shall be paid a contingency fee in accordance with the requirements set forth in Section 4, Attachment 4.5 of the District of Columbia Medicaid State Plan and federal requirements set forth at 42 CFR § 455.510.

9300.5

All audits performed by the Medicaid Recovery Audit Contractor (RAC) shall be subject to the billing standards of the District of Columbia (District) Medicaid program.

9300.6

The following claims and payments may be excluded from review and audit under the Medicaid RAC Program:

(a) Claims associated with managed care, waiver, and demonstration programs;

(b) Payments made for Indirect Medical Education and Graduate Medical Education;

(c) Claims reimbursed more than three (3) years prior to the date of the RAC review or audit;

(d) Claims that require reconciliation due to beneficiary liability; and

(e) Unpaid claims.

9300.7

In accordance with 42 CFR §§ 455.506(c) and 455.508(g), DHCF shall ensure that no claim audited under the Medicaid RAC Program has been or is currently being audited by another entity.

9300.8

DHCF shall reserve the right to limit the Medicaid RAC Program audit period by claim type, provider type, or for any other reason where DHCF believes it is in the best interest of the Medicaid program to limit claim review. Timely notice of this action shall be made to the Medicaid RAC in writing, by letter, or via email.

9300.9

Effective June l, 2021, DHCF shall suspend operation of the Medicaid RAC Program until notice is provided through further rulemaking and contingent on continued approval by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS).

D.C. Mun. Regs. tit. 29, r. 29-9300

Final Rulemaking published at 63 DCR 1914 (2/19/2016); amended by Final Rulemaking published at 67 DCR 3715 (4/3/2020); amended by Final Rulemaking published at 68 DCR 8237 (8/20/2021)