996

PROVIDER OF DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES

996.1

A provider/supplier of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) shall be governed by Chapter 94 of Title 29 District of Columbia Municipal Regulations (DCMR), the requirements set forth in this section, and the policies and procedures located in the D.C. Medicaid DMEPOS Provider/Supplier Billing Manual provided by the Department of Health Care Finance (DHCF).

996.2

A provider/supplier of DMEPOS shall:

1. (a) Operate a business that furnishes Medicare-covered items in compliance with all applicable federal and District of Columbia licensure and regulatory requirements;
2. (b) Be eligible to engage in DMEPOS business once the provider/supplier application has been submitted and approved and the provider/supplier has participated in the Medicaid DMEPOS New Provider/Supplier Training conducted by DHCF and signed a Medicaid Provider Agreement;
3. (c) Maintain a physical facility that contains space for storing business records, including the supplier's delivery, maintenance, and beneficiary communication records;
4. (d) Be prohibited from using a post office box as a primary business address;
5. (e) Be open for business at least forty (40) hours per week in a week that does not contain a holiday a weekday holiday in for which DHCF is closed and be open for business at least thirty-two (32) hours per week in a week that does contain a weekday holiday for which DHCF is closed;
6. (f) Maintain a visible sign that states the name of the provider/supplier and the hours of operation;
7. (g) Permit on-site inspections to be conducted by the Centers for Medicare and Medicaid Services (CMS), its agents, the Department of Health (DOH), DHCF or the agents of DOH or DHCF to determine supplier compliance with all applicable laws;
8. (h) Promote and maintain a beneficiary's right to privacy when services include fittings of DMEPOS;

(i) Provide patient education on the proper use of services and/or equipment;

(j) Maintain a primary business telephone number listed under the name of the business locally and, if appropriate, a toll-free telephone number for Medicaid beneficiaries. The exclusive use of a beeper number, answering service, pager, telephone line connected to a facsimile machine, or wireless telephone does not satisfy the requirement to have a primary business telephone; and

(k) Submit a document commonly known as a CMS Medicare Supplier Letter issued pursuant to 42 C.F.R. § 424.510 to evidence enrollment of the supplier in the Medicare program.

996.3 A provider/supplier shall maintain, at minimum, comprehensive liability insurance in the amount of three hundred thousand dollars ($300,000.00) and shall provide proof of such insurance to DHCF with its initial application and annually thereafter.

996.4 Each applicant and provider/supplier shall post a continuous surety bond in the amount of fifty thousand dollars ($50,000) against all DMEPOS claims, suits, judgments, or damages including court costs and attorneys' fees arising out of the negligence or omissions of the provider/supplier in the course of providing services to a Medicaid beneficiary or a person believed to be a Medicaid beneficiary. The number of bonds required shall be predicated upon each provider's DME National Provider/Supplier Identification Number (NPI). The DMEPOS provider/supplier categories are as follows:

(a) An existing provider/supplier who is providing services in the D.C. Medicaid program;

(b) A new applicant seeking to become a provider/supplier in the D.C. Medicaid program; or

(c) A provider/supplier who is submitting a new application to change the ownership of an existing enrolled provider, pursuant to § 996.6.

996.5 A provider/supplier shall be required to re-enroll in the Medicaid DMEPOS Program at least once every three (3) years.

996.6 A provider/supplier shall be re-enrolled in the Medicaid DMEPOS Program immediately after any change in business ownership.

996.7 A provider/supplier shall be required to submit required certifications, licenses,

permits or any other official information concerning the backgrounds of all employees, licensed or unlicensed, that will interact with Medicaid beneficiaries.

996.8 A provider/supplier shall submit the following information:- (a) A list of all principals of the entity;

- (b) A list of all stockholders owning or controlling ten percent (10%) or more of outstanding shares;

- (c) The names of all board members and their affiliations;

- (d) A roster of key personnel; and

- (e) An organizational chart.996.9 A provider/supplier shall maintain all Medicaid-related records for a period of ten (10) years after the date of service or sale.996.10 A provider/supplier shall fill orders, fabricate, or fit items from its inventory or by contracting with other companies for the purchase of items necessary to fill the order.996.11 At the time of product delivery or service, the provider/supplier shall provide the beneficiary with a contact telephone number for assistance.996.12 A business formed within the geographical boundaries of the District of Columbia seeking enrollment in the District of Columbia Medicaid DMEPOS Program shall be considered an in-state business.996.13 An in-state business shall submit a business license to DHCF.996.14 A business formed outside of the geographical boundaries of the District of Columbia is considered an out-of-state business.996.15 An out-of-state business shall be enrolled in a Medicaid program located within the state of its principal place of business before seeking enrollment in the District Medicaid DMEPOS Program.996.16 An out-of-state business shall submit all of the following that apply:- (a) A Certificate of Registration to transact business within the District of Columbia issued pursuant to D.C. Official Code § 47-2026.;

1. (b) The name, business address, and telephone number of its registered agent for the out-of-state business;
2. (c) Proof of a business address and a business telephone number within the District of Columbia listed under the name of the business for the purpose of providing Medicaid sales and services; and
3. (d) The Medicaid enrollment provider/supplier number from the state where the out-of-state business' principal place of business is located.996.17 DHCF shall review an applicant's signed and completed application within thirty (30) business days from its receipt by DHCF.996.18 DHCF shall return a provider/supplier application package to the applicant when DHCF determines the provider/supplier application package to be incomplete or to contain incorrect information only two (2) times within a twelve (12) month period.996.19 A DMEPOS Provider/Supplier Enrollment Application may be denied due to any one or more of the following factors:- (a) The applicant has demonstrated an inability to provide services, conduct business, or operate a financially viable entity;
4. (b) Current availability of similar services or supplies for beneficiaries taking into account geographic location and reasonable travel time;
5. (c) Number of providers/suppliers of the same type of service or supplies enrolled in the same geographic area;
6. (d) False representation or omission of any material fact by the applicant in making the application;
7. (e) Exclusion, suspension, or termination of the applicant from any Medicaid program;
8. (f) Exclusion, suspension, or termination of the applicant from any program managed by DHCF;
9. (g) Conviction of the applicant for any criminal offense relating to the delivery of any goods or services for a Medicaid beneficiary;
10. (h) Conviction of the applicant for any criminal offense relating to fraud, theft, embezzlement, fiduciary responsibility, or other financial

misconduct;

(i) Violation of federal or District of Columbia laws, rules, or regulations governing the D.C. Medicaid program by the applicant;

(j) Violation of federal or state laws, rules, or regulations governing a Medicaid program in another state by the applicant;

(k) The applicant has been previously been found by a licensing, certifying, or professional standards board to have violated the standards or conditions relating to licensure or certification of the services provided;

(l) Exclusion, suspension, or termination of the applicant from any Medicare program; or

(m) DHCF has returned a provider/supplier application package to the applicant that is incomplete or contains incorrect information at least two (2) times in the past twelve (12) months.

996.20 An applicant whose provider/supplier application has been denied may resubmit a provider/supplier enrollment application for review and a decision.

996.21 An applicant whose provider/supplier application has been approved to become a D.C. Medicaid DMEPOS Provider is deemed to be enrolled when the applicant has:

(a) Successfully completed the DMEPOS Application that is approved by DHCF;

(b) Signed a District of Columbia Medicaid Provider/Supplier Agreement that has been accepted by DHCF;

(c) Participated in a mandatory Medicaid DMEPOS New Provider/Supplier Orientation conducted by DHCF or its agent; and

(d) Received the D.C. Medicaid DMEPOS Provider/Supplier Billing Manual from DHCF or its agent.

996.22 DHCF may authorize a temporary enrollment of an applicant in the case of a special circumstance when a Medicaid beneficiary requires immediate service, supplies, or equipment, subject to the following limitations:

(a) Temporary enrollment shall be for one specific occurrence involving an identifiable Medicaid beneficiary;

1. (b) Temporary enrollment shall only be made available one time to a provider/supplier; or
2. (c) Temporary enrollment may be allowed in situations when the D.C. Medicaid Program is not the primary payer.996.23 A temporary provider/supplier may become eligible to apply for enrollment in the District of Columbia DMEPOS Program anytime during temporary eligibility or subsequently thereafter.996.24 DHCF may adopt and include in the provider/supplier agreement other requirements and stipulations that it finds necessary to properly and efficiently administer the D.C. Medicaid Program.996.25 DHCF may make, or cause to be made, payments for medical assistance and related services rendered to Medicaid beneficiaries only when:- (a) The entity has a current Medicaid Provider/Supplier Agreement in effect with DHCF;
3. (b) The entity is performing services and supplying goods in accordance with federal and District laws; and
4. (c) The provider/supplier is eligible to provide the item or service on the date it is dispensed and the beneficiary is eligible to receive the item or service on the date the item or service is furnished.996.26 Each provider/supplier shall be subject to the administrative procedures set forth in Chapter 13 of Title 29 of the DCMR during the provider's/supplier's participation in the District Medicaid DMEPOS Program.996.27 In accordance with the requirements set forth in 42 C.F.R. § 455.470, DHCF may impose a temporary moratorium on the enrollment of DMEPOS providers/suppliers.996.28 Any provider/supplier agreement for DMEPOS in existence on or before May 30, 2008 shall be considered to have expired on December 31, 2009, unless the provider/supplier agreement for DMEPOS contains an expiration date on or before January 1, 2010. Any provider/supplier of DMEPOS whose provider/supplier agreement expires on or before January 1, 2010 is eligible to submit a new provider/supplier agreement pursuant to the rules specified in Section 996 of Title 29 of the DCMR.

SOURCE: Final Rulemaking published at 56 DCR 005930 (July 24, 2009); as amended by Final Rulemaking published at 61 DCR 11659 (November 7, 2014).