District of Columbia Administrative Code

4508 BEHAVIORAL HEALTH SERVICES 4508.1 Covered behavioral health services provided by an FQHC shall be limited to ambulatory mental health and substance abuse evaluation, treatment and management services identified by specific Current Procedural Terminology (CPT) codes. Such cod…

4509 CHANGE IN THE SCOPE OF SERVICES 4509.1 An FQHC may apply for an adjustment to its PPS rate or its APM rate (in any of the following four (4) service categories: (1) primary care; (2) behavioral health, (3) preventive and diagnostic dental services; and (4) comprehensive dent…

4510 ALLOWABLE COSTS 4510.1 The standards established in this section are to provide guidance in determining whether certain cost items will be recognized as allowable costs incurred by a FQHC in furnishing primary care, behavioral health, diagnostic and preventive dental service…

4511 EXCLUSIONS FROM ALLOWABLE COSTS 4511.1 The costs that shall be excluded from allowable costs for purposes of calculating the APM rate shall include, but not be limited to, the following: Cost of services that are outside the scope of services covered under Section 1905(a)(2)…

4512 REIMBURSEMENT FOR NEW PROVIDERS 4512.1 Each new provider seeking Medicaid reimbursement as an FQHC shall meet all of the requirements set forth in Section 4500. 4512.2 Reimbursement for services furnished by a new provider shall be determined in accordance the PPS methodolog…

4513 REIMBURSEMENT FOR OUT OF STATE PROVIDERS 4513.1 A FQHC located outside of the District of Columbia that seeks reimbursement for services furnished to District of Columbia Medicaid beneficiaries shall comply with the requirements set forth under Subsection 4500.2 and shall be…

4514 MANDATORY REPORTING REQUIREMENTS 4514.1 Each FQHC shall report to DHCF, annually, on the following two (2) measure sets: (a) HRSA UDS “Quality of Care” and “Health Outcomes and Disparities” measures which may be located at the HRSA Bureau of Primary Care website at HYPERLINK…

4515 PERFORMANCE PAYMENT 4515.1 Beginning October 1, 2017, each FQHC that elects the APM rate and meets the standards outlined in Subsection 4515.2 may be eligible to participate in the FQHC performance payment program. 4515.2 To participate in the performance payment program, a …

4516 REBASING FOR APM 4516.1 No later than January 1, 2018 and every three (3) years thereafter, the cost and financial data used to determine the APM rate shall be updated based upon audited cost reports that reflect costs that are two (2) years prior to the base year and in acc…

4517 COST REPORTING AND RECORD MAINTENANCE 4517.1 Each FQHC shall submit to DHCF a Medicaid cost report, prepared based on the accrual basis of accounting, in accordance with Generally Accepted Accounting Principles. In addition, FQHCs are required to submit their audited financi…

4518 ACCESS TO RECORDS 4518.1 Each FQHC shall grant full access to all records during announced and unannounced audits and reviews by DHCF personnel, representatives of the U.S. Department of Health and Human Services, and any authorized agent(s) or official(s) of the federal or …

4519 APPEALS 4519.1 For appeals of DHCF Payment Rate Calculations, Scope of Service Adjustments or Audit Adjustments for FQHCs the following applies: (a) At the conclusion of any required audit, payment rate or scope of service adjustment, the FQHC shall receive a notice that inc…

4599 DEFINITIONS 4599.1 For purposes of this chapter, the following terms shall have the meanings ascribed: Alternative Payment Methodology - A reimbursement model other than a Prospective Payment System Rate for services furnished by an FQHC which meets the requirements set fort…

4600 GENERAL PROVISIONS 4600.1 The provisions of this chapter governing conditions of participation for providers of Mobile Community Outreach Treatment Team services shall be in support and furtherance of the following goals: (a) To establish MCOTT programs which are self-contai…

4601 APPLICATION FOR CERTIFICATION 4601.1 An application to participate in the Medicaid/MCOTT Program shall be filed on forms provided by MAA. 4601.2 The MCOTT Application shall contain, but not be limited to, the following information: (a) Name and address of the Provider organi…

4602 GENERAL CERTIFICATION REQUIREMENTS 4602.1 Each Provider's MCOTT office facility shall comply with all applicable federal and local laws and codes pertaining to health and fire safety, drug procurement and distribution, disposal of medications and controlled substances, build…

4603 STAFFING AND ADMINISTRATION 4603.1 Each MCOTT Program shall have as Program Director, a person who (1) is a licensed Psychiatrist, credentialed to practice in the District of Columbia, or a Master's Degree level clinician in social work, nursing, psychology, counseling or ot…

4604 PRIMARY CASE MANAGER 4604.1 Each MCOTT client shall have an assigned Primary Case Manager who shall be responsible for the treatment relationship with the client on an ongoing basis. 4604.2 The Primary Care Manager shall be responsible for the following: (a) Maintaining up-t…

4605 PHYSICAL PLANT REQUIREMENTS 4605.1 Each MCOTT Program office facility shall be either owned or leased by the Provider. 4605.2 Each MCOTT Program office facility shall include an accessible reception area for MCOTT clients and their families; a central team work/meeting room,…

4606 PROGRAM SERVICES 4606.1 Each MCOTT Program shall have the capability to provide comprehensive treatment, rehabilitation, and support services as a self-contained service unit. 4606.2 Each MCOTT Program shall give the highest priority to delivering individualized services out…

4607 ADMISSION REQUIREMENTS 4607.1 Each MCOTT Program shall provide services to adults who have special community mental health treatment, rehabilitation and support needs, as further defined in 4607.2, and require at least ten (10) hours a month of ongoing, face-to-face services…

4608 ASSESSMENT AND TREATMENT PLANNING 4608.1 The Program Director, Assistant Director or Psychiatrist shall complete and document an initial evaluation promptly at the time of each client's admission to the MCOTT Program. 4608.2 The MCOTT Program shall assign an Individual Treat…

4609 DISCHARGE PROCEDURES 4609.1 Providers shall discharge a client from an MCOTT Program when a client, or his/her legal representative, if any, and MCOTT Program staff mutually agree to the termination of services. Circumstances giving rise to a consideration of termination inc…

4610 TREATMENT RECORDS 4610.1 Each MCOTT Program shall keep accurate treatment records reflecting the initial, comprehensive and ongoing assessments, initial and periodic treatment plans, and the ongoing progress of each MCOTT client. The MCOTT Program staff shall document all re…

4611 REIMBURSEMENT 4611.1 Reimbursement for MCOTT services shall be at a rate established by MAA. 4611.2 MCOTT Providers shall be reimbursed at a flat rate of $ 63.00 for each day on which at least one face-to-face service for the Client is provided. 4611.3 Each Provider shall ag…

4612 RISK MANAGEMENT 4612.1 Each Provider shall develop and review annually a risk management outpatient plan consistent with 50000.115.IF of the CMHS Performance Plan, that is directed at minimizing the following as it relates to MCOTT clients: (a) Accidents; (b) Infections; (c)…

4613 AUDITS AND REVIEWS 4613.1 MAA shall perform ongoing audits, on-site visits, and reviews of MCOTT Programs to ensure that Medicaid payments are consistent with efficiency, economy and quality of care and in accordance with federal regulations governing Medicaid. 4613.2 The re…

4614 APPEALS FOR PROVIDERS AGAINST WHOM A RECOUPMENT IS MADE 4614.1 Any provider that disagrees with the reason for a recoupment or the amount of the recoupment shall have sixty (60) days from the date of the Notice of Recoupment ("NR") to submit a written request for administrat…

4615 WAIVER PROVISIONS 4615.1 MAA may grant a waiver of any requirement of these Program Standards when the MAA determines that granting a waiver would not diminish the effectiveness of the MCOTT Program, violate the purposes of the MCOTT Program, or adversely affect MCOTT client…

4699 DEFINITIONS 4699.1 When used in this chapter, the following terms and phrases have the meanings ascribed: Assessment means the process used to evaluate a client's presenting problems with an accompanying description of the reported or observed conditions to the classificatio…

4700 GENERAL PROVISIONS 4700.1 The purpose of this chapter is to establish standards under which the District of Columbia Child and Family Services Agency (CFSA) and its subcontractors, shall qualify to participate as providers of targeted case management (TCM) services. 4700.2 C…

4701 PROVIDER QUALIFICATIONS 4701.1 Each Provider shall comply with the following requirements: (a) Have the ability to access all pertinent records concerning the child's needs for services, including records of the Family Division of the District of Columbia Superior Court and …

4702 ELIGIBILITY REQUIREMENTS 4702.1 Clients eligible to receive TCM services shall be Medicaid recipients who meet the following qualifications: (a) Are twenty (20) years of age or less; and (b) Are either at risk of abuse or neglect, or are abused or neglected, and are in the c…

4703 PROGRAM SERVICES 4703.1 Each Provider shall have the capability to assist each client in gaining access to medical, social, educational or other services appropriate to the needs of the client. 4703.2 TCM services shall include, but are not limited to, the following: (a) Cli…

4704 STAFFING AND ADMINISTRATION 4704.1 Each Provider shall assign each client to an individual case manager. 4704.2 Each individual case manager shall meet the following minimum qualifications: (a) Be licensed as a graduate social worker pursuant to D.C. Code § 2-3308.2; and (b)…

4705 SUBCONTRACTS 4705.1 CFSA may, subject to MAA's written approval, subcontract the provision of TCM services. 4705.2 Each subcontract entered into by CFSA shall be submitted to MAA for approval prior to the execution of the subcontract. 4705.3 MAA shall notify CFSA, in writing…

4706 TREATMENT RECORDS 4706.1 Each Provider shall keep accurate treatment records reflecting the initial and ongoing assessments, initial and periodic treatment case plans, and the ongoing progress of each client. 4706.2 Each Provider shall document each service provided to an in…

4707 ACCESS TO RECORDS 4707.1 Each Provider shall allow appropriate personnel of the Department of Health and other authorized agents of the District of Columbia government and the federal government full access to the records for audit purposes. 4707.2 Each Provider shall mainta…

4708 REIMBURSEMENT 4708.1 An interim rate shall be developed for reimbursement of TCM services based on unaudited costs as reported by CFSA. The final rate paid to CFSA shall not exceed the actual cost incurred by CFSA in providing services to the target population. 4708.2 The in…

4709 AUDITS AND REVIEWS 4709.1 MAA shall perform ongoing audits to ensure that Medicaid payments are consistent with efficiency, economy and quality of care, and made in accordance with federal and District rules governing Medicaid. 4709.2 The audit process shall be routinely con…

4710 APPEALS - GENERAL 4710.1 CFSA shall have sixty days from the date of the NR to submit a written request for administrative review of the NR. The request for administrative review of the NR shall be submitted to the Chief, Office of Program Integrity, Utilization Review and C…

4711 APPEAL OF ADJUSTMENTS TO THE PAYMENT RATE 4711.1 After completion of an audit of CFSA's reported costs, MAA shall provide CFSA with a written notice of its determination of any adjustment to the payment rate. The notice shall include the following: (a) A description of the r…

4712 EFFECTIVE DATE 4712.1 These rules shall govern all claims for TCM services provided by CFSA or its subcontractors occurring on or after July 1, 1999. SOURCE: Emergency Rulemaking published at 47 DCR 5257 (June 23, 2000) [EXPIRED]; as amended by Final Rulemaking published at …

4799 DEFINITIONS 4799.1 When used in this chapter, the following terms and phrases shall have the following meanings: Case management services - Those services that assist an eligible individual in accessing needed medical, social, educational, and other services appropriate to t…

4800 INPATIENT SERVICES: GENERAL PROVISIONS Effective for inpatient hospital discharges occurring on or after October 1, 2014, Medicaid reimbursement for inpatient hospital discharges shall be on All Patient Refined Diagnosis Related Groups (APR-DRGs) prospective payment system (…

4801 INPATIENT SERVICES: CALCULATION OF DISTRICT-WIDE BASE RATE For Medicaid reimbursement of inpatient hospital discharges occurring on or after October 1, 2014, DHCF shall use a single, District-wide base rate for all general hospitals. Effective October 1, 2014, and annually t…

4802 INPATIENT SERVICES: CALCULATION OF COST-TO-CHARGE RATIO (CCR) For Medicaid reimbursement of inpatient hospital discharges, hospital-specific cost-to-charge ratios (CCRs) shall be calculated annually. The CCR shall be developed based on each hospital’s submitted cost reports …

4803 INPATIENT SERVICES: CALCULATION OF THE HOSPITAL-SPECIFIC COST PER DISCHARGE For Medicaid reimbursement of inpatient hospital discharges, the hospital specific cost per discharge shall equal a hospital’s Medicaid inpatient operating costs standardized for indirect medical edu…

4804 INPATIENT SERVICES: INDIRECT MEDICAL EDUCATION (IME) For Medicaid reimbursement of inpatient hospital discharges, the amount of the hospital-specific cost per discharge adjusted for IME shall be added to the District-wide base rate for each in-District general hospital to de…

4805 INPATIENT SERVICES: DIRECT MEDICAL EDUCATION (DME) For Medicaid reimbursement of inpatient hospital discharges, DME shall be a per-discharge add-on payment for each in-District general hospital that is eligible for DME. The DME add-on shall be calculated annually by dividing…