9302.1A Medicaid provider may be subject to recoupment or reconciliation of claims based on the Medicaid RAC findings.

9302.2A determination of overpayment or underpayment shall be based on, but not limited to, one or more of the following:

1. (a) Whether the service underlying the claim is covered under the District Medicaid program;
2. (b) Whether the claim resulting from the service was priced correctly in accordance with billing standards for the District Medicaid program;
3. (c) Whether the provider properly coded the claim in accordance with billing standards for the District Medicaid program;
4. (d) Whether the claim duplicates a previously paid claim; and/or
5. (e) Whether the Medicaid Management Information System (MMIS) failed to apply relevant payment policies.

9302.3 DHCF or the Medicaid RAC shall notify a provider, in accordance with the requirements set forth in Chapter 13 of Title 29 DCMR, when a claim is subject to recoupment based on the Medicaid RAC's determination.

9302.4 Pursuant to Chapter 13 of Title 29 DCMR, a provider may appeal an overpayment determination by the Medicaid RAC to the Office of Administrative Hearings (OAH) within fifteen (15) calendar days of the date the final notice of recoupment was sent to the provider.

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