D.C. Mun. Regs. tit. 29, § 9400
9400.1 Health care providers, including individual practitioners, institutional providers, and providers of medical equipment or goods related to care, seeking to provide services or goods to District of Columbia (District) Medicaid beneficiaries shall be screened and enrolled in the District Medicaid program pursuant to the requirements in this chapter. A comprehensive list of the types of providers eligible to enroll in District Medicaid is available online at www.dc-medicaid.com. This chapter also establishes screening and enrollment related circumstances that may lead the Department of Health Care Finance (DHCF) to initiate termination of enrollment of an existing District Medicaid provider. Such terminations shall proceed in accordance with the Medicaid Program Administrative Procedures set forth in 29 DCMR §§ 1300 et seq.
9400.2 Only those providers that have received notification from DHCF that screening and enrollment requirements have been met shall be authorized to receive reimbursement for health services and goods delivered to District Medicaid beneficiaries.
9400.3 To initiate the enrollment process, a provider shall submit a completed D.C. Medicaid Provider Application (application) using the online portal accessible via www.dc-medicaid.com and in accordance with all requirements set forth in this chapter.
9400.4 Providers shall be subject to any or all of the following types of screening:
(a) Ownership and Financial Disclosures;
(b) Criminal Background Checks;
(c) Fingerprinting; and
(d) Pre- and Post-Enrollment Site Visits.
9400.5 Each provider shall submit all documentation listed on the application required for that provider type, submit to screening, and adhere to the guidance and timeframes issued by DHCF throughout the process for enrollment or revalidation of enrollment.
9400.6 In accordance with 42 CFR §§ 455.414 and 455.452, DHCF shall revalidate enrollment for all District Medicaid providers as follows:
(a) For Medicaid providers designated as “limited” or “moderate” risk, revalidation shall be required every five (5) years;
(b) For Medicaid providers designated as “high” risk, revalidation shall be required every three (3) years; and
(c) The date for revalidation of enrollment shall be calculated beginning on the effective date of the Medicaid provider agreement, or the date of the Medicaid provider’s most recent revalidation, whichever is later.
9400.7 A revalidating provider shall submit to DHCF all information required for revalidation within the thirty (30) calendar days prior to the designated enrollment expiration date, in accordance with the following:
(a) If a revalidating provider fails to submit the required information to DHCF within this timeframe, DHCF shall initiate termination proceedings on or after the enrollment expiration date, in accordance with 29 DCMR §§ 1300 et seq.;
(b) If DHCF initiates termination proceedings, any claims submitted by the provider for services delivered on or after the enrollment expiration date shall not be eligible for payment by DHCF;
(c) If a provider has been terminated, the provider must submit a new application in order to participate as a District Medicaid provider; and
(d) DHCF will not terminate a provider agreement because it is beyond the expiration date, as long as complete revalidation materials are received thirty (30) calendar days prior to the expiration date and under DHCF review.
9400.8 For the duration of a provider’s enrollment in District Medicaid, each provider shall have a continuous obligation to:
(a) Maintain required licensure and submit proof of renewal for any required license prior to its expiration date. Failure to submit such proof of renewal prior to expiration shall result in DHCF’s termination of the existing Medicaid provider agreement; and
(b) Maintain an active National Provider Identification (NPI) number.
9400.9 DHCF shall screen all applications for initial enrollment, re-enrollment, and revalidation of enrollment, including those providers who have been screened by Medicare or another state’s Medicaid program within the twelve (12) month period preceding the submission of the application.
9400.10 All enrolled providers that are authorized to submit claims to and/or receive payment from Medicaid shall, as a condition of continued enrollment, submit
quarterly data to DHCF on the number of individuals served or encountered with Limited English Proficiency (LEP) or Non-English Proficiency (NEP), and the non-English languages spoken by each LEP/NEP individual served or encountered. Information and guidance on how to submit the data is available at www.dc-medicaid.com.
9400.11 In accordance with 42 CFR § 455.470(a), DHCF may impose a temporary moratorium on enrollment under any provider type if the Secretary of the U.S. Department of Health and Human Services (Secretary) imposes a moratorium on the same provider type's participation in the Medicaid program.
9400.12 In accordance with 42 CFR § 455.470(b), DHCF may impose a temporary moratorium on the enrollment of new providers, or otherwise limit the number of enrolled providers, if DHCF identifies significant potential for fraud, waste, and abuse and the Secretary concurs with DHCF's findings.
9400.13 Temporary moratoria imposed by DHCF shall be for an initial period of one hundred eighty (180) days and may be extended by increments of one hundred eighty (180) days. DHCF must document in writing the necessity for extending the moratorium.
9400.14 Out-of-District providers shall be licensed and enrolled by the single state agency for the administration of Medicaid in the state where the provider is located and shall provide documentation of enrollment in that state's Medicaid program, including proof that the provider is currently licensed without restriction.
9400.15 In accordance with § 5005(b)(2) of the 21st Century Cures Act (Pub.L. 114-255; 42 USC § 1396u-2(d)(6)), effective January 1, 2018, all individuals and entities delivering services or items to Medicaid beneficiaries pursuant to a contract with a District Medicaid managed care organization shall be screened and enrolled pursuant to the requirements in this chapter. If such individuals and entities deliver services or goods, but do not bill Medicaid directly, they may enroll using the procedures outlined in § 9400.16.
9400.16 Any provider who does not bill Medicaid directly for services rendered, but does order, refer, or prescribe services or goods for District Medicaid beneficiaries must:
(a) Maintain current licensure under state law to order, refer, or prescribe the medical services or items that are the subject of the order, referral, or prescription;
(b) Complete and submit a streamlined application for enrollment in District Medicaid;
(c) Be screened and enrolled in District Medicaid as a participating provider pursuant to the requirements set forth in this chapter; and
(d) Abstain from submitting claims to Medicaid for payment of any service.
9400.17 The requirements set forth in § 9400.16(b)-(c) apply only to provider types that are eligible to enroll in District Medicaid, as indicated by their inclusion on the comprehensive list referenced at § 9400.1.
SOURCE: Final Rulemaking published at 60 DCR 10041 (July 12, 2013); as amended by Final Rulemaking published at 68 DCR 4255 (April 23, 2021).