CurrentDistrict of Columbia Department of Health Care FinancePolicy Transmittal # 22-01

Reimbursement of Out-of-Pocket Expenditures for Managed Care Medicaid Beneficiaries

Customize your policy alerts

Sign up for District of Columbia Department of Health Care Finance Policy Transmittal # 22-01 alerts

Get alerted when Policy Transmittal # 22-01 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This document governs how District of Columbia Medicaid managed care beneficiaries submit claims for reimbursement of medical expenses paid out of pocket, and how DHCF and Medicaid managed care organizations process, decide, communicate, and appeal those claims. It applies to DC Medicaid MCOs and their enrolled beneficiaries.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyReimbursement of Out-of-Pocket Expenditures for Managed Care Medicaid Beneficiaries

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 20, 2022

Next Review DateN/A

Key ActionMCOs must investigate reimbursement claims and issue a final written determination within 60 days of receipt.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsReimbursement request deadline

60 daysMCO determination deadline

5 working daysMCO payment after missed deadline

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentDistrict of Columbia Department of Health Care FinancePolicy Transmittal # 22-01

Reimbursement of Out-of-Pocket Expenditures for Managed Care Medicaid Beneficiaries

Customize your policy alerts

Sign up for District of Columbia Department of Health Care Finance Policy Transmittal # 22-01 alerts

Get alerted when Policy Transmittal # 22-01 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyReimbursement of Out-of-Pocket Expenditures for Managed Care Medicaid Beneficiaries

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 20, 2022

Next Review DateN/A

Key ActionMCOs must investigate reimbursement claims and issue a final written determination within 60 days of receipt.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsReimbursement request deadline

60 daysMCO determination deadline

5 working daysMCO payment after missed deadline

Reimbursement Coverage and Determination Criteria

Conditions for reimbursement

Reimbursement is subject to all of the following conditions, and the MCO is not required to reimburse a claim unless it concerns medical assistance the MCO was obligated to provide under its DHCF contract.

ALL of the following

The beneficiary was eligible for Medicaid when the medical service was provided.
The beneficiary was enrolled in the MCO when the expense was incurred.
The medical expense, such as a prescription, doctor visit, or hospitalization, was medically necessary.
The medical expense was covered under Medicaid.
The reimbursement request was submitted within six months after the medical expense was incurred.Within six months
The claim concerns the type of medical assistance that the MCO was obligated to provide under its contract with DHCF.

Claim determination outcomes

Claims may be fully paid, partially paid, or denied. Any denial in whole or in part must include detailed reasons and due-process appeal information.

ALL of the following

ANY of the following
- Full payment of the claim.
- Partial payment of the claim, with a full explanation of the reasons for denying the remaining portion.
- Denial of the claim, with a full explanation of the reasons for denial.
For each claim element denied in whole or in part, the written determination must separately explain the basis for the denial in understandable language and provide as much detail as possible.

Submission, Determination, and Appeal Deadlines

Reimbursement request submission period

Submission deadlineWithin six months after the medical expense was incurred

DHCF claim forwarding period

DHCF forwarding deadlineWithin 30 days from the date the claim was submitted

MCO claim investigation and final determination period

Investigation and determination deadline60 days from receipt of the claim

Written appeal resolution period

Claims Processing, Notices, Appeals, and Payment Obligations

Billing Rule

DHCF Intake and Referral of Reimbursement Claims

DHCF receives reimbursement claims from the beneficiary or representative, verifies whether the beneficiary was enrolled in an MCO when the expense occurred, and, when applicable, notifies the beneficiary that the MCO will decide the claim and explains appeal and fair-hearing rights. DHCF must forward the claim and notice letter to the MCO within 30 days after submission.

Claims may be submitted to DHCF using the Medicaid Reimbursement Form, which is available in Spanish, French, Chinese, Korean, Amharic, and Vietnamese.
Reimbursement requires that the beneficiary was Medicaid-eligible and enrolled in the MCO when the service was provided, the expense was medically necessary and Medicaid-covered, and the request was submitted within six months after the expense.
DHCF must forward the claim and notice to the MCO and inform the enrollee that the MCO will determine the claim.

Key Terms

MCO

DefinitionManaged care organization with which the Medicaid beneficiary was enrolled when the medical expense was incurred.

Reimbursement claim

DefinitionA request submitted by a Medicaid enrollee or representative to DHCF or an MCO seeking repayment for a medical expense paid out of pocket.

Reimbursement eligibility conditions

Medicaid eligibilityThe beneficiary was eligible for Medicaid when the medical service was provided.

MCO enrollmentThe beneficiary was enrolled in the MCO when the expense was incurred.

Documentation Required

MCO Investigation and Final Determination

The MCO must investigate every reimbursement claim received directly from the beneficiary or referred by DHCF and mail a final written determination within 60 days of receipt. The determination must be full payment, partial payment with a complete explanation for each denied portion, or denial with a complete explanation; the MCO is responsible only for medical assistance it would have been required to provide under its DHCF contract.

Investigate and issue the final written determination within 60 days of receiving the claim.
For partial or full denials, explain separately the basis for each denied element in as much detail as possible.
The determination must include the claimant’s due-process appeal rights.

Denial Risk

Required Adverse Determination Notice

Every denial, in whole or in part, must contain a separate explanation for each denied element, written in language understandable at approximately a fifth-grade reading level. The notice must state the right to appeal with the MCO and explain that an appeal may be filed orally or in writing, including the required written follow-up after an oral appeal.

Use the required denial statement identifying the reimbursement request and the reasons for denial.
Provide the MCO Enrollee Services appeal contact name or department, telephone number, and address.
Tell the claimant that an oral appeal must be followed by a written statement within 10 days unless the MCO has already decided the appeal.
Explain that the claimant will receive a written resolution within 60 calendar days unless the MCO provides written reasons it cannot decide within that period; the total period may not exceed 30 working days.
Include fair-hearing rights, assistance and document-access rights, interpreter and TTY/TTD access, and available legal-assistance information.

Note

Appeal and Fair-Hearing Sequence

A claimant must appeal the MCO’s reimbursement decision before requesting a fair hearing. A fair hearing may be requested only after the MCO issues a final adverse determination on the appeal; the claimant then has 120 days from receipt of that determination to request a hearing.

The MCO appeal may be filed orally or in writing; an oral appeal generally requires a written statement within 10 days unless the MCO has already decided it.
The MCO’s written appeal resolution must state whether payment is full, partial, or denied and, if denied, the reason and fair-hearing right.
Submit the fair-hearing request to the D.C. Office of Administrative Hearings, 441 4th Street, NW, Suite 450 North, Washington, DC 20001, telephone 202-442-9094.
An Office of Administrative Hearings decision may be appealed to the D.C. Court of Appeals within 30 days after the final order is mailed.
Claimants may request records and other information needed to understand and challenge the determination, reasonable assistance, competent interpreter services, and toll-free TTY/TTD access.