10305.1 DHCF's Division of Program Integrity, or its designee, shall perform ongoing audits to ensure that an HSS agency's services for which Medicaid payments are made are consistent with programmatic duties, documentation, and reimbursement requirements as required under this chapter.

10305.2 The audit process shall be routinely conducted by DHCF, or its designee, to determine, by statistically valid sampling, the appropriateness of services rendered to HSS beneficiaries and billed to Medicaid.

10305.3 If DHCF, or its designee, denies a claim during an audit, DHCF shall recoup, by the most expeditious means available, those monies erroneously paid to the provider for denied claims, following the process for administrative review as outlined below:

(a) DHCF, or its designee, shall issue a Notice of Proposed Medicaid Overpayment Recovery (NPMOR), which sets forth the reasons for the recoupment, including the specific reference to the sections of the statute, rules, or provider agreement, the amount to be recouped, and the procedures for requesting an administrative review;

(b) The HSS agency shall have thirty (30) days from the date of the NPMOR to submit documentary evidence and written argument to DHCF against the proposed action;

(c) The documentary evidence and written agreement shall include a specific description of the item to be reviewed, the reason for the request for review, the relief requested, and documentation in support of the relief requested;

(d) Based on review of the documentary evidence and written argument, DHCF, or its designee, shall issue a Final Notice of Medicaid Overpayment Recovery (FNMOR);

(e) Within fifteen (15) days of receipt of the FNMOR, the HSS agency may appeal the written determination by filing a written notice of appeal with the Office of Administrative Hearings (OAH); and

(f) Filing an appeal with the OAH shall not stay any action to recover any overpayment.

10305.4 The recoupment amounts for denied claims may be determined by the following formula:

1. (a) The total number of denied paid claims from the audited sample shall be divided by the total number of all paid claims from the audited sample;
2. (b) The resulting quotient shall be multiplied by the total dollars paid by DHCF to the HSS agency during the audit period; and
3. (c) The resulting product shall be the amount of funds to recoup from the HSS agency.10305.5 All participant, personnel, and program administrative and fiscal records shall be maintained so that they are accessible and readily retrievable for inspection and review by DHCF, DHCF's designee, DHS, other District of Columbia officials, and representatives of HHS, as requested.10305.6 All records and documents required to be kept under this chapter and other applicable laws and regulations shall be produced for inspection within twenty-four (24) hours, or within a shorter reasonable time if necessary upon request of the auditor.10305.7 DHCF shall have grounds to terminate the HSS agency's Medicaid Provider Agreement based on the failure of an HSS agency to release or to grant access to program documents and records to the auditors in a timely manner, after reasonable notice by DHCF to the HSS agency to produce the same.10305.8 DHCF shall retain the right to conduct audits or reviews at any time. Each HSS agency shall grant full access, during announced and unannounced on-site audits or review by DHCF, DHCF's designee, DHS, other District of Columbia officials, and representatives of HHS, to relevant financial records, statistical data to verify costs previously reported to DHCF, program documentation, and any other documentation relevant to the administration and provision of HSS.10305.9 As part of the audit process, HSS agencies shall grant access to any of the following documents to the auditors, which may include, but are not limited to:- (a) A record of all service authorization and prior authorization for services;
4. (b) A record of all requests for change in services;
5. (c) A schedule of the beneficiary's activities in the community, if applicable, including strategies to execute goals in the PCSP, the date and time of the activities, and staff, as identified in the PCSP;
6. (d) Any records relating to adjudication of claims, including, the number of units of the delivered service, the period during which the service was delivered and

dates of service, and the name, signature, and credentials of the HSS provider; and

(e) Any record necessary to demonstrate compliance with rules, requirements, guidelines, and standard for implementation and administration of HSS.

SOURCE: Final Rulemaking published at 69 DCR 006426 (June 3, 2022).