9403 MEDICAID PROVIDER SCREENING

9403.1 Pursuant to 42 CFR § 455.450, DHCF shall screen all applications for initial enrollment, re-enrollment, or revalidation of enrollment based on the level of categorical risk to which the provider type is assigned.

9403.2 All providers shall be assigned to one of the following categorical risk levels:

1. (a) Limited (subject to the screening requirements described in § 9404);
2. (b) Moderate (subject to the screening requirements described in § 9405); or
3. (c) High (subject to the screening requirements described in § 9406).

9403.3 A provider applying to enroll as multiple provider types shall be screened separately for each application submitted to DHCF.

9403.4 Pursuant to 42 CFR § 455.450(e), DHCF shall elevate the categorical risk level of a particular provider from “limited” or “moderate” to “high” risk when any of the following occurs:

1. (a) The provider has been excluded from federal health care programs by the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services within the previous ten (10) years;
2. (b) The provider has been excluded from another state’s Medicaid program within the previous ten (10) years;
3. (c) DHCF or CMS lifted a temporary moratorium for the particular provider type during the previous six (6) months, and a provider that had been prevented from enrolling based on the moratorium applies for enrollment at any time within six (6) months from the date the moratorium was lifted;
4. (d) Medicare elevates the categorical risk level for the provider type;
5. (e) DHCF has imposed a payment suspension against the provider based on a credible allegation of fraud, waste, or abuse; or
6. (f) The provider has an existing Medicaid overpayment.

9403.5 DHCF may rely on, but is not limited to, the results of provider screenings performed by:

(a) Medicare contractors;

(b) Federal and State Medicaid agencies, including CMS;

(c) Children’s Health Insurance Programs (CHIP); or

(d) Other District agencies, including the Department of Health, the Department of Behavioral Health, and the Department on Disability Services.

SOURCE: Final Rulemaking published at 60 DCR 10041 (July 12, 2013); as amended by Final Rulemaking published at 68 DCR 4255 (April 23, 2021).