996

PROVIDER OF DURABLE MEDICAL EQUIPMENT, PROSTHETICS AND ORTHOTICS SUPPLIES

996.1

A provider of Durable Medical Equipment, Prosthetics, and Orthotics Supplies (DMEPOS) shall be governed by the policies and procedures located in the Provider Handbook for Durable Medical Equipment Prosthetics and Orthotics Supplies provided by the Department of Health Care Finance (DHCF).

996.2

A provider 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 has participated in the Medicaid DMEPOS New Provider Training conducted by DHCF and signed a Medicaid DMEPOS Provider Agreement accepted by DHCF;
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 where DHCF is closed on a weekday and be open for business at least thirty-two (32) hours per week in a week that does contain a holiday where DHCF is closed on a weekday;
6. (f) Maintain a visible sign that states the name of the provider and posted 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;
9. (i) Provide patient education on the proper use of services and/or equipment;
10. (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 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 shall post a continuous surety bond in the amount of fifty thousand dollars ($50,000) against all DME claims, suits, judgments, or damages including court costs and attorneys' fees arising out of the negligence or omissions of the provider 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 Identification Number (NPI). The DMEPOS provider categories shall be determined as follows:

1. (a) An existing provider who is providing services in the D.C. Medicaid program;
2. (b) A new applicant seeking to become a provider in the D.C. Medicaid program; or
3. (c) A provider who is submitting a new application to change the ownership of an existing enrolled provider, pursuant to §996.6.

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

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

996.7 A provider 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 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 shall maintain all Medicaid-related records for a period of ten (10) years after the date of service or sale.

996.10 A provider 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 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 to DHCF a business license, if required, and a Notice of Business Tax Registration pursuant to D.C. Official Code § 47-2026 (2001).

996.14 A business formed outside of the geographical boundaries of the District of Columbia shall be considered an out-of-state business.

996.15 An out-of-state business seeking enrollment in the District Medicaid DMEPOS Program shall first be enrolled in a Medicaid program located within the state of its principal place of business.

996.16 An out-of-state business shall submit all of the following that apply:

(a) A Certificate of Authority to transact business within the District of Columbia issued pursuant to D.C. Official Code § 29-101.99 et seq. (2001) if the business is a corporation;

(b) A Certificate of Registration to transact business within the District of Columbia issued pursuant to D.C. Official Code § 29-1053 et seq. (2001)

if the business is a limited liability company;

(c) The name of its registered agent for the out-of-state business along with the business address and telephone number of the registered agent;

(d) Proof of a physical 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

(e) The Medicaid enrollment provider 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 application package to the applicant when DHCF determines the provider 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 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;

(b) Current availability of services or supplies for beneficiaries taking into account geographic location and reasonable travel time;

(c) Number of providers of the same type of service or supplies enrolled in the same geographic area;

(d) False representation or omission of any material fact in making the application;

(e) Exclusion, suspension, or termination from any Medicaid program;

(f) Exclusion, suspension, or termination from any program managed by DHCF;

(g) Conviction of any criminal offense relating to the delivery of any goods or services for a Medicaid beneficiary;

(h) Conviction of 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;

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

(k) The applicant has been previously 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 from any Medicare program; or

(m) DHCF has returned a provider 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 application has been denied, may resubmit a provider enrollment application for review and a decision.

996.21 An applicant, whose provider 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 DMEPOS Provider Agreement that has been accepted by DHCF;

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

(d) Received the DHCF Provider Handbook for Durable Medical Equipment Prosthetics and Orthotics Supplies 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;

(b) Temporary enrollment shall only be made available one time to a provider; or

1. (c) Temporary enrollment may be allowed in situations when the D.C. Medicaid Program is not the primary payer.996.23 A temporary provider 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 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 DMEPOS Provider Agreement in effect with DHCF;
2. (b) The entity is performing services and supplying goods in accordance with federal and District laws; and
3. (c) The provider 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 shall be subject to the administrative procedures set forth in Chapter 13 of Title 29 of the District of Columbia Municipal Regulations during the provider's participation in the District Medicaid DMEPOS Program.996.27 DHCF shall have the authority to implement a one hundred eighty (180) day moratorium on the enrollment of DMEPOS providers when the action is necessary to safeguard public funds or to maintain the fiscal integrity of the program. This moratorium may be extended or repeated when DHCF determines this action is necessary to further safeguard public funds or to maintain the fiscal integrity of the program.996.28 Any provider agreement for DMEPOS in existence on or before May 30, 2008 shall expire on December 31, 2009, unless the provider agreement for DMEPOS contains an expiration date on or before January 1, 2010. Any provider of DMEPOS whose provider agreement expires on or before January 1, 2010 is eligible to submit a new provider agreement pursuant to the rules specified in Section 996 of Chapter 9 of Title 29 of the D.C. Municipal Regulations.

SOURCE: Final Rulemaking published at 56 DCR 005930 (July 24, 2009).