900.1 Provider claims for reimbursement shall not be honored if they reach the payment agency more than ninety (90) days after the date of service, except as otherwise provided in this section.

900.2 The time limitation shall not apply to retroactive adjustments paid to providers that are reimbursed under a retrospective payment system.

900.3 If a claim for payment under Medicare has been filed in a timely manner, the agency may pay a Medicaid claim or residual relating to the same services within six (6) months after the agency or provider receives notice of the disposition of the Medicare claim.

900.4 The time limitation shall not apply to claims from providers under investigation for fraud or abuse.

900.5 The agency shall make payments at any time in accordance with a court order; to carry out hearing decisions or agency corrective actions taken to resolve a dispute; or to extend the benefits of a hearing decision, corrective action, or court order to others in the same situation as those directly affected by it.

900.6 The time limitation shall not apply when it can be established that billing to a third party delayed submission of the claim.

900.7 The time limitation shall not apply to the Medicaid eligibility spend-down provisions.

900.8 The time limitation shall not apply to retroactive Medicaid eligibility determinations.

900.9 The time limitation shall not apply to health maintenance organizations (HMOs) or prepaid capitation grants.

900.10 The time limitation shall not apply to providers that are located outside of the metropolitan area who provide services to Title XIX eligibles.

900.11 The time limitation shall not apply to services for foster children or services to wards of the District.

900.12 The time limitation shall not apply to individuals who apply for Medicaid on the basis of disability.

AUTHORITY: Unless otherwise noted, the authority for this chapter is Reorganization Plan No. 2 of 1979, 3 D.C. Code, 2001 Ed. at 338.

SOURCE: Final Rulemaking published at 28 DCR 4791 (November 6, 1981).