D.C. Mun. Regs. tit. 22, r. 22-A6403

Current through Register Vol. 71, No. 42, October 18, 2024

Rule 22-A6403 - ADDITIONAL REIMBURSEMENT REQUIREMENTS

6403.1

The following provisions apply to the reimbursement of substance user disorder (SUD) providers billing the Department or the Department of Health Care Finance pursuant to this chapter, except where otherwise noted.

6403.2

Reimbursement for Short-term MMIWM services shall not exceed five (5) days unless a longer stay is authorized by the Department.

6403.3

H0010 or H0010HK shall be billed for locally- funded clients in MMIWM. Residential treatment room and board (H0043 and H0043HK) is not a separate service for these clients and shall not be billed in addition to MMIWM.

6403.4

H0010U1 or H0010U1HK shall be billed for Medicaid clients in MMIWM. Residential treatment room and board (H0043 and H0043HK) shall be billed separately for these clients in order to be reimbursed.

6403.5

Reimbursement will not be provided for the following services for clients in MMIWM:

(a) Medication Management;

(b) Clinical Care Coordination;

(c) Medication Assisted Treatment;

(d) Drug Screening; and

(e) Crisis Intervention.

6403.6

The Department shall reimburse an SUD provider for a maximum of one (1) Initial Diagnostic Assessment per client within a thirty (30)-day period.

6403.7

The Department shall reimburse an SUD provider for a maximum of one (1) Comprehensive Diagnostic Assessment per client per level of care (LOC).

6403.8

The Department shall reimburse an SUD provider for a maximum of two (2) Ongoing Diagnostic Assessments per client per sixty (60) days.

6403.9

Comprehensive Diagnostic Assessment and Ongoing Diagnostic Assessment shall not be billed on the same day.

6403.10

Clinical Care Coordination shall not be billed in conjunction with staff's clinical supervision or at the same time as any Diagnostic Assessment service.

6403.11

The following reimbursement limits shall apply, per LOC, to Crisis Intervention:

(a) Level 1: Eighty (80) units;

(b) Level Opioid Treatment Program ("OTP "): One hundred and forty- four (144) units;

(c) Level 2: One hundred and twenty (120) units; and

(d) Level 3: One hundred and sixty (160) units.

6403.12

The following reimbursement limits shall apply, per LOC, to SUD Counseling/Therapy. The Department may approve additional units with justification.

(a) Level 1: Thirty-two (32) units per week;

(b) Level 2: Eighty (80) units per week; and

(c) Level 3: One hundred (100) units per week.

6403.13

No more than ninety-six (96) units of Medication Management shall be billed per LOC. Medication Management shall not be billed for observing the self-administration of medication.

6403.14

The following provisions apply to reimbursement for all medications dispensed in OTPs:

(a) Medication shall be billed on a per-dose basis; and

(b) A single fifteen (15)-minute administration session may be billed when an individual is receiving take-home doses.

6403.15

The following provisions further apply to reimbursement of methad one administered in OTPs:

(a) A client can be dispensed a maximum of one dose per day;

(b) An initial and second authorization can be authorized for a maximum of ninety (90) days each; subsequent authorizations cannot exceed one hundred and eighty (180) days each; and

(c) Prior authorization from the Department is required for reimbursement of more than two- hundred and fifty (250) units of medication in one calendar year. The maximum quantity of medication and administration services over a twelve (12)- month period is three hundred and sixty- five (365) units.

6403.16

All claims seeking Medicaid or local only reimbursement under this Chapter shall include the active National Provider Identification (NPI) numbers for the certified provider and the rendering provider. The rendering provider is the staff member who provided the service.

D.C. Mun. Regs. tit. 22, r. 22-A6403

Final Rulemaking published at 67 DCR 11430 (10/2/2020); amended by Final Rulemaking published at 69 DCR 13495 (11/4/2022)