9410.1 Upon the occurrence of any of the circumstances described in this Section, any action taken by DHCF to terminate an existing provider agreement shall occur in accordance with the Medicaid Program Administrative Procedures set forth in 29 DCMR §§ 1300 et seq.

9410.2 In accordance with 42 CFR §§ 455.416 and 455.452, DHCF shall deny an application for enrollment or initiate termination of the provider agreement in all of the following circumstances:

1. (a) The provider was terminated on or after January 1, 2011, under Title XVIII of the Social Security Act, or under the Medicaid program or Children's Health Insurance Program (CHIP) of any other state;
2. (b) Any individual with a five percent (5%) or greater direct or indirect ownership interest in the provider failed to submit timely and accurate information and cooperate with any screening methods required under 42 CFR Part 455 Subpart E;
3. (c) The provider or any individual with an ownership or control interest in the provider, or who is an agent or managing employee of the provider, fails to submit timely or accurate information, unless DHCF determines that denial or termination is not in the best interests of the District's Medicaid program and documents this determination in writing;
4. (d) The provider, any individual with a five percent (5%) or greater direct or indirect ownership interest in the provider, or any individual who is an agent or managing employee of the provider, has been convicted of a criminal offense related to Medicare, Medicaid, or CHIP within the last ten (10) years, unless DHCF determines that denial or termination is not in the best interests of the District's Medicaid program and documents this determination in writing;
5. (e) The provider, or any individual with a five percent (5%) or greater direct or indirect ownership interest in the provider, fails to submit fingerprints in the form and manner determined by DHCF within thirty (30) calendar days of a request by CMS or DHCF, unless DHCF determines that denial or termination is not in the best interests of the District's Medicaid program and documents this determination in writing;
6. (f) The provider fails to permit access to provider locations for any site visits required pursuant to 42 CFR § 455.432, unless DHCF determines that

denial or termination is not in the best interests of the District's Medicaid program and documents this determination in writing; or

(g) The provider fails to comply with the terms of the provider agreement or any applicable District Medicaid program rules or requirements.

9410.3 In accordance with 42 CFR §§ 455.416 and 455.452, DHCF may deny an application for enrollment or initiate termination of the provider agreement of a provider if CMS or DHCF determines any of the following:

1. (a) The provider falsified any information provided on or in support of the application;
2. (b) The provider made a material omission on the application; or
3. (c) The provider's identity cannot be verified.

9410.4 DHCF shall enforce all terminations that result from the Secretary of the U.S. Department of Health and Human Services mandatorily excluding individuals or entities from participating in any federal or state health care program, pursuant to 42 USC § 1320a-7(a), including any of the following:

1. (a) Conviction of program-related crimes;
2. (b) Conviction relating to patient abuse;
3. (c) Felony conviction relating to health care fraud; or
4. (d) Felony conviction relating to a controlled substance.

9410.5 DHCF shall enforce all terminations that result from the Secretary of the U.S. Department of Health and Human Services permissively excluding individuals and entities from participating in any federal or state health care program, pursuant to 42 USC § 1320a-7(b), for any of the following:

1. (a) Conviction relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct;
2. (b) Conviction in connection with the interference with, or obstruction of, any investigation or audit related to the use of funds received, directly or indirectly, from any federally funded health care program;
3. (c) Misdemeanor conviction relating to a controlled substance;

1. (d) License revocation or suspension by a state licensing authority, including surrendering of such a license held while formal disciplinary proceeding is pending;
2. (e) Exclusion, suspension, or sanction from any federal or state program involving the provision of health care, including programs administered by the Department of Defense and Department of Veterans Affairs;
3. (f) Submission of claims reflecting excessive charges and/or unnecessary services;
4. (g) Failure to provide medically necessary services, and thereby adversely impacting covered individuals;
5. (h) Committing acts that constitute fraud, facilitate kickbacks, and/or support other prohibited activities, pursuant to 42 USC §§ 1320a-7a, 1320a-7b, or 1320a-8;
6. (i) Allowing a sanctioned individual to hold a five percent (5%) or greater direct or indirect ownership or control interest, serve as an officer, director, agent, or managing employee;
7. (j) Allowing an individual to hold a direct or indirect ownership or control interest in a sanctioned entity when the individual knows, or should know, of the action that resulted in conviction or exclusion from Medicare or a state health care program;
8. (k) Failure to disclose information required to process an application or revalidate enrollment, including requested information on subcontractors and/or suppliers;
9. (l) Failure to permit examination of records supporting payment;
10. (m) Failure to grant immediate access, upon reasonable request, to the Secretary, or designee; the Inspector General of the Department of Health and Human Services; or representatives of DHCF or the Medicaid Fraud Control Unit;
11. (n) Failure of a hospital to comply substantially with corrective action commenced in accordance with 42 USC § 1395ww(f)(2)(B);
12. (o) Default on health education loan or scholarship obligations by an individual, except physicians who provide unique services to the community serviced; or

1. (p) Making false statements or misrepresentation of material facts in any application, agreement, bid, or contract to participate or enroll as a provider or supplier under a federal health care program.9410.6 DHCF shall adhere to federal guidelines governing terminations that occur pursuant to this Section, as set forth in §§ 1128C through 1128G of the Social Security Act (42 USC §§ 1320a-7c through 1320a-7h).9410.7 In accordance with 42 CFR § 455.16, DHCF shall initiate termination proceedings against a provider when the results of its own investigation indicate that the provider has done any of the following:- (a) Made or caused to be made any false statement or misrepresentation of material fact in claiming, or in determining the right to, payment under the District Medicaid program;
2. (b) Furnished or ordered services under the District Medicaid program that are substantially in excess of the beneficiary's needs or that fail to meet professionally recognized standards for health care;
3. (c) Submitted or caused to be submitted to the District Medicaid program bills or requests for payment containing charges or costs that are substantially in excess of customary charges or costs; or
4. (d) Engaged in any other act of fraud or abuse related to the District Medicaid program.9410.8 Nothing in this section shall supersede or lessen the force of any other laws or regulations that govern provider participation in the Medicaid program, including the Medicaid Fraud Enforcement and Recovery Amendment Act (D.C. Law 19-232; D.C. Official Code §§ 2-381.01 et seq. (2016 Repl.)) and any subsequent amendments thereto.9410.9 Any provider who is classified as 'limited' risk and who is denied enrollment or terminated from District Medicaid program participation shall be barred from participation with the District Medicaid program for three (3) years from the date of denial or termination.9410.10 Any provider who is classified as 'high' risk or 'moderate' risk and who is denied enrollment or terminated from District Medicaid program participation shall be barred from participation with the District Medicaid program for five (5) years from the date of denial or termination.

9410.11 Any provider who is denied enrollment or terminated from District Medicaid program participation more than one (1) time shall be permanently barred from participation with the District Medicaid program.

9410.12 In accordance with Chapter 37 of Title 27 DCMR and Section III.A of the provider agreement, the Director may terminate a provider's enrollment with the District Medicaid program for convenience by serving written notice upon the provider in a manner that provides proof of receipt or proof of valid attempt to deliver (e.g. certified mail, return receipt requested, hand delivery) at least ninety (90) calendar days in advance of the proposed termination.

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