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. § 1396a(a)(42)(B)(i)), and 42 C.F.R. §§ 455.500 et 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 All audits performed by the Medicaid RAC shall be subject to the billing standards of the District of Columbia (District) Medicaid program.

9300.5 The following claims and payments may be excluded from review and audit under the Medicaid RAC Program:

1. (a) Claims associated with managed care, waiver, and demonstration programs;
2. (b) Payments made for Indirect Medical Education (IME) and Graduate Medical Education (GME);
3. (c) Claims older than three (3) years from the date of reimbursement;
4. (d) Claims that require reconciliation due to beneficiary liability; and
5. (e) Unpaid claims.

9300.6 In accordance with 42 C.F.R. §§ 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.

9300.7 DHCF shall reserve the right to limit the Medicaid RAC Program audit period by claim type, provider type, or by any other reason where DHCF believes it is in the best interest of the Medicaid program to limit claim review. Notice to the Medicaid RAC of this action shall be in writing and may be communicated through e-mail.

SOURCE: Final Rulemaking published at 63 DCR 1915 (February 19, 2016).