District of Columbia Administrative Code

5504 REQUIRED INFORMATION 5504.1 Each QO shall submit the following information to the Department, at the time of application for a contract: (a) A copy of the basic organizational documents of the QO, such as articles of incorporation, and each amendment; (b) A copy of the by-la…

5505 MARKETING PRACTICES 5505.1 The QO shall submit to the Department for prior written approval all marketing plans, procedures and materials including the following items: (a) Marketing brochures and fliers; (b) Advertising copy and public service announcements; (c) Enrollment …

5506 EVIDENCE OF COVERAGE 5506.1 Each QO shall prepare and submit for prior written approval of the Department a form that is evidence of coverage. 5506.2 The QO shall provide each enrollee with written evidence of coverage prior to the effective date of enrollment which shall in…

5507 SERVICE DELIVERY AND QUALITY ASSURANCE PROVISIONS 5507.1 The QO shall provide each enrollee with health care of consistent quality, delivered with dignity, at locations which assure reasonable availability and accessibility to enrollees. 5507.2 The QO shall provide, or arran…

5508 ENROLLEE GRIEVANCE SYSTEM 5508.1 Each QO shall establish and maintain a grievance system with reasonable procedures for the prompt resolution of complaints initiated by enrollees. 5508.2 Each QO shall submit its plans and procedures for a grievance system to the Department f…

5509 ENROLLMENT AND DISENROLLMENT PROCEDURES 5509.1 Enrollment by Medicaid recipients shall be voluntary and without regard to any of the following: (a) Health status or need or services; (b) Physical or mental condition or handicap; (c) Age; (d) Sex; (e) National origin; (f) Rac…

5510 MEDICAID PROGRAM AND RECIPIENTS HELD HARMLESS 5510.1 A QO shall hold harmless the District of Columbia government, the Department, and Medicaid recipients against any loss, damage, expense and liability of any kind arising out of any action of the QO in the service of Medica…

5511 ASSIGNMENT OF RIGHTS 5511.1 No QO shall assign or transfer any of the rights gained by qualifying as contractor to the Department SOURCE: Final Rulemaking published at 34 DCR 1550, 1563 (March 6, 1987). AUTHORITY: DC-DCMR Unless otherwise noted, the authority for this chapte…

5512 SANCTIONS FOR NON-COMPLIANCE 5512.1 If the Department determined that a QO has failed to comply with this chapter or other applicable federal and District laws and regulations, the Department may do any of the following: (a) Suspend further enrollment of Medicaid recipients;…

5513 THIRD PARTY LIABILITY RECOVERY 5513.1 The QO shall attempt and require its subcontractors to attempt to recover monies resulting from third party liability cases involving workman’s compensation, accidental injury suits and other subrogation of benefits settlements. 5513.2 T…

5514 CONFIDENTIALITY OF INFORMATION 5514.1 All information, records and data collected and maintained by the QO or its subcontractors relating to enrollees shall be protected by the QO from unauthorized disclosure. 5514.2 Except as otherwise provided in Federal law or regulations…

5515 PAYMENT FOR SERVICES 5515.1 The QO shall be paid by the Department on a monthly per capita basis for the services it gives to Medicaid enrollees pursuant to its Medicaid benefits package. 5515.2 Each QO shall file with the Department both its community rate worksheets, and c…

5516 ACCESS TO INFORMATION 5516.1 The Department may make an examination of the affairs of any QO and its subcontractors including onsite inspections and periodic medical audits as often as is reasonably necessary for the protection of the interests of the Department and Medicaid…

5599 DEFINITIONS 5599.1 When used in this chapter, the following terms and phrases shall have the meanings ascribed: Community rate - the system under which prepaid providers set rates on per person or per family basis that are equivalent for all individuals and for all families …

600 MINOR'S HEALTH CONSENT 600.1 Any person who is eighteen (18) years of age or older may consent to the provision of health services for himself or herself, or for his or her child or spouse. 600.2 Any minor who is seventeen (17) years of age or more may consent to voluntarily …

601 FINANCIAL RESPONSIBILITY 601.1 A minor who consents to the provision of health services to himself or herself, or to the minor's child, under the terms of this chapter shall be liable for the payment of the services rendered pursuant to this chapter. 601.2 The spouse, parent,…

602 LIABILITY OF PROVIDER 602.1 No physician, surgeon, dentist, or health or mental care facility shall be compelled against his, her, or its best judgment to treat a minor on the minor's own consent. 602.2 A physician, surgeon, dentist, or health or mental care facility that ref…

603 CONTRACEPTIVE INFORMATION, SERVICES, AND DEVICES FOR MINORS 603.1 Birth control information, services, and devices shall be provided by the health facilities operated by the District of Columbia, and may be provided by any qualified person or institution, without regard to th…

605 DAY NURSERIES 605.1 It shall be unlawful for any person, persons, corporation, or association to establish or maintain a day nursery, nursery school, boarding school, boarding house, foster family home, home, or other place within the District for the reception, board, or car…

610 STUDENT ACCESS TO TREATMENT 610.1 A student may possess and self-administer medication at a school in which the student is enrolled, at school-sponsored activities, and while on school-sponsored transportation, for the treatment of asthma, anaphylaxis, and diabetes, provided …

620 CONCUSSION PROTECTION 620.1 The provisions of this section shall apply to: (a) Any athletic activity sponsored by a school; (b) Any athletic activity sponsored by the Department of Parks and Recreation (c) Any athletic activity sponsored by a private for-profit or nonprofit o…

699 DEFINITIONS 699.1 When used in this chapter, the following words and phrases shall have the meanings ascribed: Administer—the direct application of medication to the human body whether by ingestion, inhalation, subcutaneous and intramuscular injection, or topical means. Agent…

6000 ESTABLISHMENT OF INTERNAL GRIEVANCE PROCESS 6000.1 Each insurer shall establish and maintain an internal grievance system that provides for the presentation and resolution of grievances brought by members or member representatives. 6000.2 A member or member representative sh…

6001 REQUIREMENTS FOR INTERNAL GRIEVANCE SYSTEM 6001.1 Each insurer's internal grievance system shall include the following: (a) The right of a member or member representative to file a grievance regarding any aspect of the insurer's health care services related to the adverse de…

6002 INFORMAL INTERNAL REVIEW 6002.1 Any member dissatisfied with an adverse decision shall be provided an opportunity to discuss and review the decision with the insurer's medical director, physician or other designee who rendered the decision. 6002.2 The member has the right to…

6003 FORMAL INTERNAL REVIEW 6003.1 A member or member representative dissatisfied with the grievance decision rendered in the informal internal review process may seek a formal internal review before a reviewer, physician, or panel of physicians, advanced practice registered nurs…

6004 EXPEDITED REVIEW PROCESS IN EMERGENCY OR URGENT MEDICAL CONDITION CASES 6004.1 An expedited review is required for an adverse decision involving an emergency or urgent medical condition in accordance with this section if: (a) The adverse decision is rendered for health care …

6005 EXHAUSTION OF INTERNAL REVIEW PROCESS 6005.1 Except as provided in § 6005.2, a member or member representative shall exhaust the insurer's internal grievance process prior to filing a request for an external review with the Director under this chapter. Medicaid recipients ne…

6006 GENERAL PROCEDURES FOR EXTERNAL REVIEW 6006.1 Within thirty (30) business days after the date of receipt of an adverse formal internal review grievance decision, the member or member representative may file a request for an external review with the Director. 6006.2 Each memb…

6007 EXTERNAL REVIEW OF ADVERSE GRIEVANCE DECISIONS 6007.1 Upon the filing of a request for an external review, the Director shall make the determinations required under §107(c) of the Act, D.C. Code, 2001 Ed. §44-301.07(c), and shall notify the member, member representative and …

6008 INDEPENDENT REVIEW ORGANIZATIONS 6008.1 Each entity or organization seeking to operate as an IRO shall be certified by the Director. 6008.2 Each organization or entity seeking certification shall submit to the Director an application for certification as an IRO on a form spe…

6009 DENIAL, SUSPENSION AND REVOCATION OF CERTIFICATION 6009.1 The Director may deny an application for certification and suspend or revoke a certification issued to an IRO pursuant to the Act and these rules if: (a) The Director finds that the entity or organization does not mee…

6010 CONDUCT OF EXTERNAL REVIEWS 6010.1 The IRO, in conducting external reviews assigned by the Director, shall use at least two (2) physicians licensed to practice medicine in the District of Columbia, Maryland or Virginia, except that: (a) Medical reviewers licensed elsewhere i…

6011 EXTERNAL REVIEW HEARINGS 6011.1 The IRO shall schedule and hold a hearing within the District of Columbia as soon as possible after receiving a request for a hearing from a member or a member representative, but in no event later than fifteen (15) business days after receipt…

6012 ANNUAL REPORT OF INDEPENDENT REVIEW ORGANIZATIONS 6012.1 Each IRO shall submit to the Director on or before October 30th of each year an annual report. 6012.2 The annual report shall include the following information: (a) Name and address of the reporting IRO; (b) The report…

6013 ASSESSMENT OF THE INSURER 6013.1 In accordance with § 109 of the Act, D.C. Code, 2001 Ed. §44-301.09, the Director or a designee shall annually send a Notice of Assessment to each insurer. The assessment payable by each insurer shall be calculated by taking the total cost of…

6014 NON-APPLICABILITY OF RULES 6014.1 These rules shall not apply in cases directly involving coverage determinations or benefit requirements under the Federal Medicare Program. SOURCE: Final Rulemaking published at 47 DCR 229 (January 14, 2000). AUTHORITY: DC-DCMR Unless otherw…

6099 DEFINITIONS 6099.1 The following terms shall have the meanings ascribed below: Act - means the Health Benefits Plan Members Bill of Rights Act of 1998, effective April 27, 1999, D.C. Code, 2001 Ed. §§44-301.01 to 44-304.01. Adverse decision - means a determination made by an…

6100 GENERAL PROVISIONS 6100.1 The provisions of this chapter shall apply to an applicant for, or recipient of, loan repayment funds under the District of Columbia Health Professional Recruitment Program Act of 2005, effective March 8, 2006 (Act) (D.C. Law 16-71; D.C. Official Co…

6101 APPLICATION FOR PARTICIPATION IN PROGRAM 6101.1 An applicant proposing to provide services at an approved Service Obligation Site that is not in a MUA is eligible for loan repayment if the applicant provides services related to the HPSA designation where the Service Obligati…

6102 RENEWAL OF PARTICIPATION IN PROGRAM 6102.1 A participant in the Health Professional Recruitment Program who has completed the original contracted two (2) year term of service may apply to renew his or her contract for up to two (2) additional years of service. The maximum te…

6103 REVIEW AND APPROVAL OF APPLICATION 6103.1 The Director shall review each application and provide a written decision to each applicant by March 1 for the first application period and by September 1 for the second application period. The Director shall provide a written reason…

6104 RETENTION OF APPLICATIONS 6104.1 The Department shall not be required to keep on file a rejected application for more than two (2) months after the applicant is notified of his/her rejection. 6104.2 An applicant receiving notice of rejection may reclaim the application no la…

6105 REAPPLICATION 6105.1 An applicant who is not accepted into the Program for any reason may re-apply during any subsequent application cycle. Source: Final Rulemaking published at 57 DCR 7667, 7671 (August 20, 2010). AUTHORITY: DC-DCMR Section 17 of the District of Columbia He…

6106 PARTICIPATION CONTRACTS 6106.1 Each participant in the Program shall sign a contract with the Department of Health setting out the terms and conditions of his or her participation. 6106.2 An applicant who receives preliminary notice of approval of his or her application shal…

6107 INVOICES 6107.1 A participant shall submit an invoice for each quarter of service on a form provided by the Department of Health. 6107.2 Once completed with all required information, the form shall be scanned and attached to an e-mail to the appropriate Department personnel.…

6108 ELIGIBLE SITES 6108.1 In order to be eligible to participate in the Program, the applicant or participant must provide primary care, mental health, or dental services at a site approved by the Director as a Service Obligation Site. 6108.2 The following are eligible to become…

6199 DEFINITIONS 6199.1 For the purpose of this chapter, the following terms shall have the meanings ascribed below: Act—the District of Columbia Health Professional Recruitment Program Act of 2005, effective March 8, 2006 (D.C. Law 16-71; D.C. Official Code § 7-751.01 et seq.). …

6700 GENERAL PROVISIONS 6700.1 The purpose of the radiation provisions of this title (chapters 67 through 69) is to specify the requirements in the use of all radiation, radiation machines, and radioactive materials to ensure the maximum protection of the public health and the ma…