D.C. Mun. Regs. tit. 29, r. 29-7112

Current through Register 71, No. 45, November 7, 2024

Rule 29-7112 - REIMBURSEMENT

7112.1

DHCF and the Lead Agency shall identify policies and procedures for allocating financial responsibility for EI services through a Memorandum of Understanding.

7112.2

The Lead Agency shall take all responsible measures to ascertain the legal liabilities of third-party payers prior to billing Medicaid. Rendering providers shall bill OSSE's EI program for Medicaid covered services.

7112.3

In accordance with 42 U.S.C. § 1396, the Lead Agency shall utilize public insurance, such as Medicaid's (Title XIX) and the EPSDT benefit, to the maximum extent possible within the limits of the program.

7112.4

The Lead Agency shall agree to accept as payment in full the amount determined by DHCF as Medicaid reimbursement for the authorized services provided to beneficiaries pursuant to § 7115. Rendering providers shall not bill the beneficiary or any member of the beneficiary's family for EI services.

7112.5

Reimbursement to the Lead Agency for EI services shall be available when:

(a) Described in the IFSP according to the amount, scope, and duration of services required;

(b) Ordered by qualified health care professionals who shall be licensed practitioners of the healing arts, as set forth in 42 C.F.R. §§ 440.60, 440.110, 440.130, and 440.167, the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986, as amended (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01et seq.), implementing rules, and any subsequent amendments thereto; and

(c) The Lead Agency has provided a parent or authorized caregiver with written notification of IDEA no-cost protections and confidentiality provisions.

7112.6

Medicaid reimbursement for EI services shall not include:

(a) Traveling, training, waiting, or preparation of reports;

(b) Therapeutic services that are not developmentally-based, but required due to, or as part of, a medical procedure, a medical intervention, or an injury, unless the condition has become chronic or sub-acute;

(c) Services not documented in the IFSP, other than the initial and periodic assessments;

(d) Services rendered in a clinic or provider's office without justification for the location;

(e) Service coordination; and

(f) Services provided in the absence of the child, with the exception of IFSP team meetings, which do not include the child.

D.C. Mun. Regs. tit. 29, r. 29-7112

Final Rulemaking published at 61 DCR 8122 (August 8, 2014)

Authority: An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2012 Repl.)) and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)).