9203. CLAIMS RECOUPMENT OR RECONCILIATION

9203 CLAIMS RECOUPMENT OR RECONCILIATION 9203.1 For those beneficiaries dually-eligible for Medicare and Medicaid, the District’s Medicaid PPC payment adjustment policy shall also apply to those claims denied under Medicare’s preventable conditions policy. 9203.2 A Medicaid provider shall be subject to reimbursement recoupment or reconciliation based on the Medicaid Provider Preventable Conditions Payment Adjustment Policy. A determination of overpayments and/or underpayments shall be based on one (1) or more of the following factors: Whether the procedure or diagnosis underlying the claim is a PPC; Whether the condition results in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis; Whether the claim resulting from the service was priced correctly; Whether the provider properly coded the claim by using the present on admission (POA) indicator field; and Whether the claim duplicates a previously paid claim. SOURCE: Final Rulemaking published at 59 DCR 14960 (December 21, 2012).