Medicaid Provider

Your hearing request must be in writing. To make sure you include all the required information, you can use the Medicaid Provider Appeal form. You should also include with the form a copy of the notice you are appealing. The notice will normally include a deadline for filing the hearing request; however, in some cases a hearing may be obtained by a request filed after the deadline stated in the notice.

you have a lawyer, the lawyer may prefer to prepare and file the hearing request for you. you obtain a lawyer after filing a hearing request, the lawyer may decide to file an amended hearing request.

Visit the Filings & Forms page for specific filing instructions.

OAH Rule 2808 has more information about hearing requests.

The OAH Rules explain all the steps required to complete the OAH hearing process, from requesting a hearing to appealing a judge’s final decision. You can find the OAH Rules on the Rules & Laws page. You must follow the OAH Rules throughout the process.

All the rules that apply to a Medicaid Provider case are in Chapter 28. The table of contents for Chapter 28 can help guide you to the information you need.

DHCF’s regulations are often the most relevant source of legal authority in Medicaid provider cases, since DHCF is the agency that directly administers the Medicaid program in D.C. However, Medicaid is a joint federal and state program, so federal laws and regulations may also apply. This section gives a brief overview of each level of legal authority. But every case has its own facts and circumstances, so some cases may involve laws and regulations that are not included here.

The Medicaid program was enacted through Title XIX of the Social Security Act. You can find the federal laws in Title 42, Chapter 7, Subchapter XIX of the U.S. Code (USC). Federal laws regarding Medicaid state plan requirements for provider screening and oversight are in Subchapter XIX, Section 1396a, specifically Subsections (a)(39), (a)(77), (a)(78), and (kk). Federal laws for Medicaid provider screening processes are also in Subchapters XVIII, Part E, Section 1395cc, specifically in Subsection (j)(2).

Through the Social Security Act, Congress gave authority to the Centers for Medicare and Medicaid Services (CMS), a federal agency within the U.S. Department of Health and Human Services (HHS), to work with states to administer states’ Medicaid programs. CMS passes regulations and guidance that states must follow. You can find CMS regulations in Title 42, Chapter IV of the Code of Federal Regulations (CFR). Regulations for provider screening and enrollment are in Subchapter C, Part 455, Subpart E. You can also visit the CMS website for more information about CMS regulations and guidance. Other helpful resources are available on the Medicaid website.

Federal laws and regulations give broad requirements regarding how states, including D.C., must administer Medicaid programs, but each state determines most of the specifics of its program. For example, as stated in CMS regulations: “Within broad Federal rules, each State decides eligible groups, types and range of services, payment levels for services, and administrative and operating procedures.” 42 CFR § 430.0.

At the state level, each state, including D.C., must have a Medicaid “state plan” approved by CMS. The state plan is a formal agreement between the state and the federal government that allows a state to receive federal funding so long as the state agrees to follow federal laws and regulations. Among other things, the state plan designates the state agency to administer the program and specifies the scope of the state’s Medicaid program and the standards and processes for administering the program. You can find the D.C. Medicaid State Plan on DHCF’s website.

Once CMS approves a state plan, a state’s Medicaid agency may then administer the program, which includes making regulations that establish legal standards for Medicaid provider screening, enrollment, and oversight.

DHCF’s regulations for the Medicaid program are in Title 29 of the D.C. Municipal Regulations (DCMR). Chapters in this Title have specific standards and requirements that apply to most Medicaid provider cases at OAH.

Specifically, Title 29, Chapter 94 covers provider screening, enrollment, and termination. Chapter 13 covers Medicaid Program administrative procedures more generally and includes sections covering termination of provider agreements, suspension of provider payments, hearing rights, and other topics. Other Chapters may also apply, depending on the specific service. For example, Chapter 50 includes provider requirements for Personal Care Aide (PCA) services; Chapter 42 includes provider requirements for the Elderly and Persons with Disabilities (EPD) Waiver Program; and Chapter 19 includes provider requirements for the Individuals with Intellectual Disabilities (IDD) Waiver Program, which also involves the Department on Disability Services (DDS). To help guide you to chapters and sections that may apply to the issues in your case, each title, chapter, and section of the DCMR has a general heading that summarizes that portion of the regulations.

Other resources are also available to help you learn more about laws and regulations. For example, you can visit DHCF’s website and the D.C. Medicaid website for more information.

For further assistance, click on “I need more help” at the bottom of this page for information about who you can contact for help.

After you file a hearing request, generally the next step of the process will be explained in a “scheduling order” that OAH will send you by mail, and by email if you provide an email address.

The judge may first schedule a “status hearing,” also called a “status conference.” The purpose of a status hearing is for the judge to meet with the parties to generally talk about the issues in the case and next steps. The scheduling order will explain the purpose of a status hearing, but there often is not much preparation needed for a status hearing.

If needed, the case will then be scheduled for an “evidentiary hearing.” The purpose of the evidentiary hearing is for each side to give “evidence” to support their side of the case. The scheduling order for an evidentiary hearing will have specific instructions, but hearing preparation generally involves each side collecting the information they want the judge to know and planning how to present the information during the hearing.

Information you present during a hearing is called “evidence.” There are two broad categories of evidence:

• Verbal testimony (what you and other witnesses say at the hearing)
• Documents, photographs, or other physical items

For testimony, you can practice telling your side of the story before the hearing. If you have witnesses that will testify on your behalf, you can ask your witnesses to practice their testimony as well. Practicing your testimony can help make sure you and your witnesses don’t accidentally leave out important information and can help you feel more comfortable on the day of the hearing.

If a witness won’t agree to come to a hearing voluntarily, you can ask the judge for a “subpoena.” A subpoena is a court order that requires someone to come to a hearing and testify. Visit the Subpoena Request page, under “Filings & Forms,” for more information about the subpoena process.

Documents, photographs, or other items you plan to use to support your case are called “exhibits.” You should collect all your exhibits before the hearing so that you can file a copy of the exhibit with OAH and “serve” a copy on the agency by the deadline given in the scheduling order. “Serving” means delivering, mailing, or faxing a copy of the exhibit to the other party in a case. You can also serve exhibits by email if you and the agency have agreed in writing to allow service by email. You can find the contact information for DHCF and any other agency involved in the case at the end of your scheduling order, on the page called “Certificate of Service.”

If you know that an agency or a person or organization related to your case has important documents about the facts in the case, but they will not give you copies of the documents, you can ask the judge for a “subpoena” that will require them to do so. Besides requiring someone to testify at hearing, a subpoena can also be used to require someone to share documents. You can also ask the judge to allow “discovery.” Discovery is the formal process of getting information from an opposing party. Discovery generally is not needed or permitted in most OAH hearings, but it may be an option if you have a good reason. Visit the Subpoena Request and Discovery Request pages, under “Filings & Forms,” for more information about these processes.

You should also keep in mind that properly filing and serving an exhibit does not automatically mean that the judge can rely on the information in the exhibit when making a decision. Instead, you need to be prepared to introduce the exhibit during your testimony or a witness’s testimony. In other words, you or a witness will need to describe the item and may need to answer questions about it, so that the judge can be satisfied that the item is relevant to the case and is reliable. After you or a witness describe an exhibit and answer any questions from the judge or the other party, you can then ask the judge to admit the exhibit into evidence. If the judge allows the exhibit into evidence, you can then refer to the item in detail during your testimony, and the judge can rely on the item when making a decision. You need to be prepared for this process for each individual exhibit. It is a good idea to bring a list of all the exhibits you plan to use during the hearing, so you can keep track of what you have talked about and whether the judge has accepted the exhibit into evidence.

Lastly, you should have copies of all exhibits, both your own and the other party’s, when you come to your hearing. Even if your hearing is in person at OAH, OAH generally does not provide copies of the exhibits for the parties. Each party needs to bring their own copies.

Here are some of the common OAH Rules that apply to hearing preparation: Rule 2809 (Filing of Papers); Rule 2811 (How to Serve a Paper); Rule 2812 (Calculating Deadlines); Rule 2813 (Motions Procedure); Rule 2821 (Hearings and Evidence). Other rules may apply, so it is a good idea to familiarize yourself with the OAH Rules’ table of contents so that you know where to go to look for particular requirements. The OAH Rules are on the Rules & Laws page.

All exhibits must be filed with OAH and served on the other party.

You can file exhibits with OAH in person; by mail, email, or fax; or through the OAH E-Filing Portal. Visit the Filings & Forms page for specific filing instructions.

“Serving” means delivering, mailing, or faxing copies of your exhibits to the other party. If the other party has agreed in writing, you may also send exhibits by email.

Each party must file and serve exhibits by the deadline given in the scheduling order to make sure both sides have opportunity to review all the documents and other items the other side intends to use to support their case.

If you do not know the contact information for the other party, look at the “Certificate of Service” at the end of the scheduling order you receive from OAH. The Certificate of Service lists the contact information for each party.

You should look closely at your scheduling order for information about how your hearing will be held, but most OAH hearings are currently remote and are scheduled to take place by telephone. OAH uses a program called Webex to hold remote hearings, but only a phone is required for anyone to join. Visit the Webex Hearings page for more information about joining a remote hearing by phone.

If you are scheduled for a telephone hearing, you can request a video hearing or an in-person hearing, using the Request for Video Conference or In-Person Hearing form. Or, if you are scheduled for an in-person hearing, you can request to join the hearing by phone, using the Request to Participate by Telephone form.

Whether remote or in person, an evidentiary hearing is generally divided into three main parts:

• Opening statements
• Presentations of evidence
• Closing arguments

An opening statement is your chance to give the judge a broad overview of your case and what you intend to prove through your evidence. The opening statement is not testimony and does not count as evidence, however. So, remember to present all of your evidence during the next part of the hearing, even if you talked about it already in your opening statement.

The presentation of evidence is the main part of the hearing, and each side takes turns. The judge will explain the how the hearing will go before it begins, but the side with the “burden of proof” normally goes first. The side with the burden of proof must prove certain facts to win the case. For example, If DHCF decided to terminate your provider agreement, the agency must prove facts that justify that decision. If DHCF can’t do so, you win the case. But If DHCF denied your initial enrollment application, you need to prove facts to show that you meet the legal standards to become a Medicaid provider. But even if you need to prove facts to win the case, the judge may still have the agency present evidence first, since it can be helpful to have the agency explain why it made a particular decision.

When it is your turn to present evidence, you can give testimony and talk about the documents or other items you have as evidence, if the judge allowed your exhibits into evidence (see “How do I prepare for a hearing?” above for more explanation about how exhibits are admitted into evidence). You can also have your witnesses attend and ask them questions to get them to testify on your behalf. Asking questions of your own witnesses is called “direct examination.”

After you or a witness are done giving testimony, the other side can ask questions about the testimony that was given. This is called “cross examination.” Likewise, after the other side’s witnesses give testimony as part of their presentation of evidence, you will have the opportunity to ask them questions. However, neither side is required to ask cross examination questions, and the judge will not assume you agree with the testimony of the other side’s witnesses if you choose not to question them. The judge may also have questions for the parties and witnesses throughout the hearing.

Finally, after both sides have presented their evidence, each side can give a closing argument. A closing argument is not required but is your opportunity to summarize your evidence and legal arguments as to why you should win. The closing argument is not evidence, and you generally cannot introduce new exhibits during your closing or talk about information that was not admitted into evidence.

Throughout the process, keep in mind that all evidence and arguments are being given directly to the judge. An evidentiary hearing is not an opportunity for the parties to talk and argue between themselves. So, you should practice your opening statement, presentation of evidence, and closing argument as if you are speaking directly to the judge.

Finally, if you are ever confused as to what’s going on during the hearing, ask the judge to explain.

Yes. Upon request, OAH will provide a free court-certified interpreter at your hearing. You cannot have a friend or family member interpret for you during a hearing.

You may request an interpreter when you file your initial hearing request, or you may request an interpreter at any other time by calling OAH at (202) 442-9094 or by emailing [email protected]. But please let OAH know as soon as possible that you need an interpreter for your hearing to give OAH time to schedule an interpreter.

If you have not requested an interpreter by the day of your hearing, you should let the judge know that you need an interpreter, and the judge can try to get an interpreter. If the judge cannot find an interpreter right away, the judge will need to reschedule the hearing to give time for OAH to schedule an interpreter for a new hearing date.

will also provide an interpreter if you need to speak with an OAH Customer Service Representative or Resource Center staff, whether visiting in person or calling OAH by phone. Simply ask for an interpreter and identify your language when you visit or call, and OAH staff will contact an interpreter to assist.

Yes. Upon request, OAH will provide reasonable accommodations to allow you to participate in your hearing. You may request an accommodation when you file a hearing request, or you may request an accommodation at any other time by calling OAH at (202) 442-9094 or by emailing [email protected].

Please explain the accommodation you need, and OAH staff will be in touch with you to arrange reasonable accommodations for the day of your hearing. OAH may need some time to arrange the accommodations, so please let OAH know as soon as possible what accommodations you will need for your hearing.

You may ask the judge in writing for a different hearing date, also called a “continuance.”

For this type of request, you must first reach out to the other party to see if they will agree to a different hearing date. The other party doesn’t have to agree, or even respond. But you at least need to make a good faith effort to get the other party’s consent.

You then must file your request with OAH and send a copy of the request to the other party. To make sure you give OAH all the information needed for this type of request, you may use the Request for a Different Hearing Date form.

You should never assume that a request is granted. If your hearing date is approaching and you have not received a written response, contact the OAH Clerk’s Office to see if the judge has acted on your request. If the judge has not acted on the request by your hearing date, then the hearing will be held as originally scheduled and you will be required to attend.

OAH Rule 2813 has more information about filing case-related requests, also called “motions.” The OAH Rules are on the Rules & Laws page.

If you missed your hearing, and you still want a hearing, you must ask for a new hearing date in writing as soon as possible. Even if the judge sends a Final Order in the other party’s favor before you file your request, the judge can still grant a new hearing and change the final order. However, you must give a good reason for having missed the hearing. To make a request, you may complete the Request for a New Hearing form and file the form with OAH and serve a copy on the other party.

OAH Rule 2828 explains more about this type of request. OAH Rule 2813 has more information about filing case-related requests, also called “motions.” The OAH Rules are on the Rules & Laws page.

The judge will not make a final decision about your case during the hearing. Rather, the judge will take time after the hearing to carefully consider all the evidence before making a final decision in writing. The judge’s written decision is called a “final order.” The final order will be sent to all parties to the case and will explain the facts of the case as determined by the judge, the laws that apply to the case, and the judge’s legal conclusions based on how the law applies to the facts.

The final order will also explain your appeal rights, in case you disagree with the judge’s decision.

If you disagree with a final order, you may either:

• ask the OAH judge to reconsider the decision or grant relief from the final order, or
• file an appeal with the D.C. Court of Appeals.

Visit the Closed Case Forms page, under “Filings & Forms,” for more information and instructions.

If you cannot find a lawyer or choose to represent yourself, you may talk with someone with the OAH Resource Center for additional help. Please call (202)-442-9094 and press “4” from the main menu, or send an email to [email protected]. The OAH Resource Center cannot give legal advice or be your lawyer, but our staff are happy to answer questions and give general information about Medicaid provider requirements and the OAH hearing process.