District of Columbia Administrative Code

4806 INPATIENT SEVICES: CALCULATION OF RELATIVE WEIGHTS For Medicaid reimbursement of inpatient hospital discharges occurring on or after October 1, 2014, DHCF shall use hospital-Specific Relative Value (HSRV) version 31 national weights for APR-DRGs. The HSRV method adjusts for …

4807 INPATIENT SERVICES: CALCULATION OF CAPITAL ADD-ON PAYMENTS For Medicaid reimbursement of inpatient hospital discharges, Capital payments shall be per-discharge add-on payments that apply to in-District general hospitals only. For discharges occurring on or after October 1, 2…

4808 INPATIENT SERVICES: CALCULATION OF OUTLIER PAYMENTS For Medicaid reimbursement of inpatient hospital discharges, the APR-DRG PPS shall provide an additional payment for outliers, high-cost and low-cost, based on inpatient costs. For discharges on or after October 1, 2014, DH…

4809 INPATIENT SERVICES: POLICY ADJUSTOR(S) DHCF may utilize policy adjustors to increase or decrease APR-DRG relative weights for certain care categories or for a range of DRGs to meet policy goals. For Medicaid reimbursement of inpatient hospital discharges occurring on or afte…

4810 INPATIENT SERVICES: SPECIAL CONSIDERATION FOR HOSPITALS LOCATED IN ECONOMIC DEVELOPMENT ZONES A general hospital whose primary location is in an area identified as an Economic Development Zone and certified by the District’s Department of Small and Local Business Development…

4811 INPATIENT SERVICES: TRANSFER AND ABBREVIATED STAY PAYMENT For each claim for Medicaid reimbursement involving a beneficiary transfer to another general hospital, DHCF shall pay the transferring hospital the lesser of the otherwise applicable DRG base payment amount or a pror…

INPATIENT SERVICES: SHORT-TERM STAYS AND INELIGIBLE DAYS DHCF shall deny claims for Medicaid reimbursement arising out of a patient admission and discharge on the same date (same-day discharge); and shall instruct the billing provider to bill the services as outpatient services. …

4813 INPATIENT SERVICES: THIRD PARTY LIABILITY AND PATIENT COST-SHARING For Medicaid reimbursement of inpatient hospital discharges, DHCF shall calculate the allowed amount for a service and then subtract third party liability (TPL) and patient cost-sharing in determining the act…

4814 SPECIALTY INPATIENT SERVICES: GENERAL PROVISIONS 4814.1 The District of Columbia’s Medicaid program shall reimburse claims associated with discharges from specialty hospitals, occurring on and after October 1, 2014, in accordance with the methodology described in Sections 48…

4815 SPECIALTY INPATIENT SERVICES: PER DIEM REIMBURSEMENT (PD-APR-DRG) 4815.1 Reimbursement to the specialty hospitals reimbursed on a PD basis shall be calculated as set forth in this section. 4815.2 Payment based on the PD-APR-DRG method shall be determined as follows: APR-DRG …

4816 SPECIALTY INPATIENT SERVICES: PER STAY REIMBURSEMENT (PS-APR-DRG) Reimbursement to the specialty hospitals reimbursed on a PS basis shall be calculated as set forth in this section. Payment based on the PS-APR-DRG method shall be determined as follows: APR-DRG RELATIVE WEIGH…

4817 SPECIALTY INPATIENT SERVICES: CALCULATION OF OUTLIER PAYMENTS FOR PS 4817.1 DHCF shall provide an additional payment for high and low cost outliers. 4817.2 For discharges on or after October 1, 2014, DHCF shall provide an additional payment for specialty inpatient stays when…

4818 SPECIALTY INPATIENT SERVICES: POLICY ADJUSTER(S) 4818.1 DHCF may apply an age-adjuster to claims associated with specialty hospital inpatient stays where the beneficiary’s age falls outside of the age range used to calculate the base rate as is typically associated with that…

4819 SPECIALTY INPATIENT SERVICES: CLAIMS SUBMISSION AND UTILIZATION CONTROL 4819.1 A specialty hospital reimbursed on a per diem basis (PD-APR-DRG) shall be required to submit a final claim using Bill Type 114. DHCF, or its designee, shall retrospectively analyze hospital claims…

4822 COST REPORT, AUDIT, AND RECORD MAINTENANCE 4822.1 All general and specialty hospitals enrolled in the District of Columbia Medicaid program shall meet the applicable cost report, audit and record maintenance requirements, as set forth in Sections 4822 and 4823, as a conditio…

4823 NOTICE AND ADMINISTRATIVE REVIEW All requests for administrative review shall be made in writing and delivered or emailed to the Department of Health care Finance, Reimbursement Analyst (Hospitals), Office of Rates, Reimbursement and Financial Analysis, 441 4th Street, NW, S…

4899 DEFINITIONS 4899.1 For the purposes of this chapter, the following terms shall have the meanings ascribed: Acute care hospital: The term “acute care hospital” shall include those hospitals providing inpatient services as defined at 42 C.F.R. § 440.10. APR-DRG Relative Weight…

4900 GENERAL PROVISIONS 4900.1 The purpose of this chapter is to establish standards governing Medicaid reimbursement for rehabilitative ("rehab") services provided by the District of Columbia Child and Family Services Agency (CFSA) and its subcontractors ("Provider"). 4900.2 CFS…

4901 ELIGIBILITY REQUIREMENTS 4901.1 Persons eligible to receive rehab services shall be Medicaid recipients who meet the following qualifications: (a) Are twenty (20) years of age or less; (b) Are determined to be abused or neglected pursuant to the Prevention of Child Abuse and…

4902 PROGRAM SERVICES 4902.1 Rehab services shall include the following services: (a) Evaluation, assessment and Plan of Care development; (b) Individual and group psychotherapy and counseling; (c) Medical evaluations, including developmental, psychological, speech/language, occu…

4903 PROVIDER QUALIFICATIONS 4903.1 Each Provider shall comply with the following requirements: (a) Have the ability to access all pertinent records concerning the client's needs for services, including records of CFSA; (b) Have established referral systems and demonstrated linka…

4904 SERVICE SETTINGS 4904.1 Rehab services shall be provided in the least restrictive setting appropriate to the client's condition, taking into account the Plan of Care and type of service. 4904.2 Rehab services provided to a client who resides outside of a family home shall be…

4905 TREATMENT RECORDS 4905.1 All phases of the client's treatment program and related information shall be reflected in the record. 4905.2 The treatment record shall include, but not be limited to, the following: (a) Complete identification data, including Medicaid number and ot…

4906 ACCESS TO RECORDS 4906.1 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. 4906.2 Each Provider shall mainta…

4907 REIMBURSEMENT 4907.1 An interim rate shall be developed for reimbursement of rehab 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. 4907.2 The …

4908 ADJUSTMENT(S) TO THE PAYMENT RATE 4908.1 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 rate adju…

4909 AUDITS AND REVIEWS 4909.1 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. 4909.2 The audit process shall be routinely con…

4999 DEFINITIONS 4999.1 When used in this chapter, the following terms and phrases shall have the following meanings: Advanced Practice Registered Nurse - A person who is licensed as an advanced practice registered nurse pursuant to the District of Columbia Health Occupations Rev…

500 GENERAL PROVISIONS 500.1 The purpose of this chapter shall be to ensure high quality pre-hospital care for children and adults in the District of Columbia. 500.2 The provisions of this chapter shall apply to every one of the following: (a) Persons performing the duties of eme…

501 AMBULANCE SERVICES 501.1 No person shall operate or hold itself out as operating an ambulance in the District unless the operator holds a currently valid certificate issued pursuant to this chapter for that ambulance. 501.2 No person shall advertise or disseminate information…

502 CERTIFICATION AS AN EMERGENCY MEDICAL SERVICES AGENCY 502.1 No person, including volunteer groups and government entities shall operate an Emergency Medical Services Agency in the District without holding a valid certification issued pursuant to this chapter, except as provid…

503 CHANGE IN INFORMATION 503.1 An Emergency Medical Services Agency shall notify the Director, in a manner that the Director prescribes, of any change in the protocols or authorized drug list of the agency no fewer than thirty (30) days prior to the change. 503.2 An Emergency Me…

504 EMERGENCY MEDICAL SERVICES AGENCIES: MEDICAL DIRECTORS 504.1 The medical director of a certified Emergency Medical Services Agency shall be responsible for maintaining the quality of the patient care provided by the Emergency Medical Services Agency and of ensuring that the E…

505 EMERGENCY MEDICAL SERVICES AGENCIES: LOCATION 505.1 An Emergency Medical Services Agency shall maintain a fixed physical location. The agency shall notify the Director no fewer than thirty (30) days prior to any change in the location before the agency moves to the new locati…

506 EMERGENCY MEDICAL SERVICES AGENCIES: STORAGE OF LINENS, EQUIPMENT, AND SUPPLIES 506.1 An Emergency Medical Services Agency shall supply adequate, clean, and enclosed storage space for linens, equipment, and supplies at each place of operation. The storage shall be maintained …

507 EMERGENCY MEDICAL SERVICES AGENCIES: RECORDS 507.1 An Emergency Medical Services Agency shall maintain records that include: (a) Approved patient care report forms; (b) Employee or member rosters; (c) Time sheets; (d) Call rosters; (e) Training records; (f) Dispatch logs, whi…

508 EMERGENCY MEDICAL SERVICES AGENCIES: LONG-TERM RESPONSES TO MUTUAL AID REQUESTS 508.1 If an emergency response vehicle of an Emergency Medical Services Agency responds on a mutual aid request that is located outside of the District of Columbia for a period that exceeds forty-…

509 EMERGENCY MEDICAL SERVICES AGENCIES: PATIENT CARE REPORTS 509.1 An Emergency Medical Services Agency shall complete a Patient Care Report (PCR) for each patient that the EMS provider sees. Each PCR shall include the name and the DOH certification number of all EMS providers w…

510 EMERGENCY MEDICAL SERVICES AGENCY VEHICLES: CERTIFICATIONS 510.1 No ground ambulance or emergency medical response vehicle shall be operated in the District of Columbia (except in response to a mutual aid agreement or as otherwise authorized by the Mayor or Director) unless i…

511 EMERGENCY MEDICAL SERVICES AGENCY VEHICLES: NON-TRANSPORT VEHICLES 511.1 An emergency medical response vehicle maintained and operated for response to the location of a medical emergency to provide immediate medical care at the basic or advanced life support level, but not to…

512 EMERGENCY MEDICAL SERVICES AGENCY VEHICLES: AIR AMBULANCES 512.1 An aircraft maintained and operated for response to the location of a medical emergency to provide immediate medical care at the basic or advanced life support level and for the transportation of patients shall …

513 EMERGENCY MEDICAL SERVICES AGENCY VEHICLES: INSPECTIONS 513.1 Each Emergency Medical Services Agency’s vehicle, its equipment, all associated records, and the premises designated in its application, shall be available for inspection by the District EMS Officer or his or her d…

514 EMERGENCY MEDICAL SERVICES AGENCY VEHICLES: OPERATING STANDARDS 514.1 The owner of an emergency medical response vehicle shall maintain the vehicle in good repair and safe operating condition and shall meet the same motor vehicle, vessel, or aircraft safety requirements as ap…

515 EMERGENCY MEDICAL SERVICES PROVIDERS 515.1 No person shall hold himself or herself out as being an emergency medical services provider in the District without holding a valid certification issued pursuant to this chapter. 515.2 An applicant for certification as an emergency m…

516 EMS PROVIDERS - EMERGENCY MEDICAL RESPONDER 516.1 Each applicant for certification as an Emergency Medical Responder (EMR) shall submit an application to the Director. The application shall include: (a) A copy of a valid NREMT-First Responder (or greater) certification card; …

517 EMS PROVIDERS - EMERGENCY MEDICAL TECHNICIAN 517.1 Each applicant for certification as an Emergency Medical Technician (EMT) shall submit an application to the Director. The application shall include: A copy of a valid NREMT-EMT (or greater) certification card; (b) A copy of …

518 EMS PROVIDERS – ADVANCED EMERGENCY MEDICAL TECHNICIAN 518.1 Each applicant for certification as an Advanced Emergency Medical Technician (AEMT) shall submit an application to the Director to be considered for a District of Columbia AEMT certification. The application shall in…

519 EMS PROVIDERS – EMERGENCY MEDICAL TECHNICIAN-INTERMEDIATE 519.1 Each applicant for certification as an Emergency Medical Technician-Intermediate (EMT-I) shall submit an application to the Director. The application shall include: A copy of a valid NREMT EMT-I99 (or greater) ce…

520 EMS PROVIDERS – PARAMEDIC 520.1 Each applicant for certification as a Paramedic shall submit an application to the Director. The application shall include: A copy of a valid NREMT Paramedic certification card; (b) A copy of a valid AHA Health Care Provider (or equivalent) CPR…

521 EMS PROVIDERS: RECERTIFICATION, REINSTATEMENT, AND OUT OF STATE APPLICATIONS 521.1 Each applicant for renewal shall submit the items required for the certification level requested to the Director no later than May 31 of the year in which his or her certification expires. 521.…