Regulation text
HYPERLINK "http://www.westlaw.com/Find/Default.wl?rs=dfa1.0&vr=2.0&DB=DC-MR&DocName=LK%2829DCADCS809%29&FindType=l" 9115 AUDITS AND REVIEWS
9115.1 This section sets forth the requirements for audits and reviews of ASURS services. DHCF shall perform regular audits of ASURS providers to ensure that Medicaid payments are consistent with efficiency, economy and quality of care, and made in accordance with federal and District conditions of payment. The audits shall be conducted at least annually and when necessary to investigate and maintain program integrity. DHCF may enter into a written memorandum of agreement with the Department of Behavioral Health (“DBH”) to perform, as DHCF’s designee, audits and reviews, described in this section, to the extent consistent with this section and DBH’s statutory authority.
9115.2 DHCF shall perform routine audits of claims to determine the appropriateness of ASURS services rendered and billed to Medicaid to ensure that Medicaid payments can be substantiated by documentation that meets the requirements set forth in this chapter, and made in accordance with federal and District rules governing Medicaid.
9115.3 If DHCF determines that claims are to be denied, DHCF shall recoup those monies erroneously paid to an ASURS provider for denied claims, following the period of Administrative Review as set forth in this rule.
9115.4 DHCF shall issue a Notice of Proposed Medicaid Overpayment Recovery (NPMOR) to the ASURS provider, which sets forth the reasons for the recoupment, the amount to be recouped, and the procedures and timeframes for requesting an Administrative Review of the PNR.
9115.5 The ASURS provider shall have thirty (30) calendar days from the date of the NPMOR to request an Administrative Review. The provider shall submit documentary evidence and/or written argument against the proposed action to DHCF in the request for an Administrative Review. If the provider fails to respond within thirty (30) calendar days, DHCF shall issue a Final Notice of Medicaid Overpayment Recovery (FNMOR), which shall include the procedures and timeframes for requesting an appeal.
9115.6 DHCF shall review the documentary evidence and/or written argument submitted by the ASURS provider against the proposed action described in the NPMOR. After this review, DHCF may cancel its proposed action, amend the reasons for the proposed recoupment and/or adjust the amount to be recouped. DHCF shall issue a FNMOR, which shall include the procedures and timeframes for requesting an appeal.
9115.7 Within fifteen (15) calendar days from date of the FNMOR, the ASURS provider may appeal the FNMOR by filing a written notice of appeal from the determination of recoupment with the Office of Administrative Hearings. The written notice requesting an appeal shall include a copy of the FNMOR, description of the item to be reviewed, the reason for review of the item, the relief requested, and any documentation in support of the relief requested.
9115.8 In lieu of the off-set of future Medicaid payments, the ASURS provider may choose to send a certified check made payable to the District of Columbia Treasurer in the amount of the funds to be recouped.
9115.9 Filing an appeal shall not stay any action to recover any overpayment except as provided in 1 DCMR § 2831.2 or DHCF, in its discretion, determines that it is in the best interest of the agency.
9115.10 Each Medicaid-enrolled ASURS provider shall allow access during an onsite audit or review to DHCF, its designee, DBH, other authorized District of Columbia government officials, the Centers for Medicare and Medicaid Services (CMS), and representatives of the United States Department of Health and Human Services, to relevant records and program documentation.
9115.11 Each Medicaid-enrolled ASURS provider shall facilitate audits and reviews by maintaining the required records and by cooperating with the authorized personnel.
SOURCE: Final Rulemaking published at 72 DCR 013719 (December 5, 2025).
District of Columbia Municipal Regulations
Public Welfare
29 DCMR § 9115