District of Columbia medical billing and payer rules

Timely filing in District of Columbia

DC law and the federal No Surprises Act

CMS found no All-Payer Model Agreement and no DC law setting the out-of-network rate, so the federal process governs insured plans. DISB enforces under an agreement with CMS.

Major payers

How does DC Medicaid work for billing?

DC Medicaid is run by the Department of Health Care Finance (DHCF), which describes itself as the District's single state Medicaid agency. Providers bill either the managed care plan the patient is enrolled in or, for the minority of members outside managed care, DHCF's fee-for-service program.

DHCF states that more than 90% of the roughly 100,000 DC Medicaid beneficiaries under 21 receive care through managed care, and about 10% stay in traditional fee-for-service. The plans pay claims, authorize services and run grievances and appeals. DHCF stays legally responsible for compliance with federal and District law.

Which managed care plans are active now?

DHCF's managed care page says the District contracts with two plans for the DC Healthy Families Program: AmeriHealth Caritas DC and MedStar Family Choice DC. A third plan, Health Services for Children with Special Needs (HSCSN), covers the Child and Adolescent Supplemental Security Income Program. DHCF Transmittal 26-19 says enrollees who were with Wellpoint DC (formerly Amerigroup DC) were assigned to AmeriHealth Caritas DC on August 1, 2026.

The same transmittal says Wellpoint remains responsible for covered services rendered through 11:59 p.m. on July 31, 2026, including inpatient admissions that run past that date. A claim for a July stay that crosses the cutoff therefore still goes to Wellpoint, not to the new plan. Enrollees have until January 31, 2027 to switch to MedStar if they dislike the assignment, so verify the plan on the date of service, every time.

What changed for prior authorizations during the transition?

From August 1 through October 31, 2026, DHCF told providers to treat referrals and prior authorizations issued before August 1 as valid through October 31, whether or not the provider contracts with AmeriHealth or MedStar. A service date after October 31 needs a fresh authorization from the receiving plan.

What does the fee-for-service claim look like?

DHCF's Transmittal 26-10 on the 2026 professional fee schedule says professional services are those billed to DC Medicaid on the CMS-1500 claim form, and that the update covers physician services, physician-administered drugs, durable medical equipment, enteral items and laboratory services. No DHCF page with hospital UB-04 billing instructions, so confirm them before a new hospital client goes live.

What is the DC Medicaid timely filing limit?

DC Medicaid pays no claim whose date of service is more than 365 days before the date of submission, for claims submitted on or after October 1, 2012. That rule comes from the District's State Plan Amendment 12-07, which CMS cleared on October 24, 2012, and DHCF announced it in Transmittal 12-28.

The first claim must itself have been filed inside the 365 days. A claim never filed on time does not get a second window.

Do managed care plans use the same limit?

Not necessarily. The amendment above governs the District's program, but each managed care plan sets filing terms in its own provider contract and manual. This page does not cover the AmeriHealth Caritas DC or MedStar manuals, so it does not state their filing windows. Pull the manual for the plan on the claim and put its limit on your work queue next to the 365-day fee-for-service limit.

Is the 2012 page still current?

It is the text CMS cleared and DHCF posted, and no later DHCF notice that changes it is cited here. It is a 2012 document and DHCF's provider manual was not reachable for us, so confirm it with DHCF before a large write-off.

Who is the Medicare contractor in DC?

Novitas Solutions is the Part A and Part B Medicare Administrative Contractor for the District of Columbia, in Jurisdiction L (JL). The CMS list of MACs by state shows JL covering Delaware, the District of Columbia, Maryland, New Jersey and Pennsylvania, so a DC provider shares a contractor with providers in neighbouring Maryland.

The CMS list is dated March 2023, so confirm the assignment on the CMS MAC page before you change a payer setup.

Medicare's filing limit is 42 CFR 424.44(a)(1): the claim must be filed no later than the close of the period ending 1 calendar year after the date of service. DC Medicaid's 180-day allowance after the Medicare disposition only helps when the Medicare claim was filed on time, so file the Medicare claim first and file it promptly. See our Medicare payer guide and Medicaid payer guide for the national rules.

What is DC's prompt payment law for insurers?

D.C. Code § 31-3132 requires a health insurer to reimburse a covered claim within 30 days after it receives a clean claim. If the insurer is late, interest starts on the 31st day, and the provider does not have to file a separate formal claim for it.

Electronic submissions get a faster presumption of receipt. That presumption matters when an insurer says a claim never arrived. Keep the clearinghouse acceptance report, because subsection (j) lets you rely on electronic confirmation of receipt as proof.

A "clean claim" in § 31-3131 is one with no material defect that substantially prevents timely payment, and a material defect means missing information the plan's own published claim filing requirements say is essential.

What stops an insurer taking money back later?

D.C. Code § 31-3133 limits retroactive denials. An insurer may take back payment for services subject to coordination of benefits only within 18 months of paying, and in other cases only within 6 months. Fraud, improperly coded claims where the insurer gave you its coding guidelines at least 30 days before the service, and duplicate claims are exceptions. After a coordination-of-benefits takeback you have 180 days from the denial to bill the plan responsible, unless the insurer allows longer.

Does DC have its own surprise billing law?

CMS says it does not. In a letter to Mayor Bowser and the DISB Commissioner dated December 8, 2021, CMS states that the District has no applicable All-Payer Model Agreement and that DC did not identify any state law governing the out-of-network rate. On that basis the letter says the federal IDR process applies to determine the out-of-network rate for items and services furnished to people in insured group or individual coverage in the District by nonparticipating providers, nonparticipating emergency facilities and air ambulance providers.

This is a 2021 letter, and the CMS applicability chart is current as of January 11, 2023, so ask DISB or re-read CMS before you rely on it for a dispute that raises a new legal question. The chart lists the District of Columbia under the "Federal IDR Process" column, not the "Bifurcated Process" column.

Can an out-of-network ER group balance bill in DC?

Under 45 CFR 149.410, a nonparticipating provider or emergency facility must not bill or hold liable an insured patient for an emergency service amount above the in-network cost-sharing, at a hospital emergency department or an independent freestanding emergency department. That is the federal rule, and the CMS letter says it applies in DC. This page cites no separate DC statute on balance billing or any DC rule on ground ambulance billing, which the federal No Surprises Act does not cover.

What does the federal process require?

Open negotiation runs 30 business days, and either party may start federal IDR within 4 business days after it ends under 45 CFR 149.510. Our out-of-network billing and IDR service page covers the full sequence, and the state surprise billing laws guide shows how DC compares with states that have their own methods.

How do you dispute an out-of-network underpayment in DC?

Start with the federal steps, since CMS says they apply to insured plans in the District. For a self-funded employer plan the answer is the same, because the federal process covers it regardless.

How do you file a complaint with DISB?

The DC Department of Insurance, Securities and Banking (DISB) takes complaints about insurers online, through a downloadable form, or by mail to 1050 First St. NE, Suite 801, Washington, DC 20002. DISB says to contact the institution first if you can, and you may ask for help at any time.

DISB says it confirms a completed complaint within three business days, names the person assigned, asks the insurer for a response, and tries to finish a case within 45 days. DISB says to file if you are a DC resident or the contract was executed in the District. If the insurer broke a DC law, DISB says it will require a correction.

Which payers matter most in DC?

For Medicaid, the active managed care plans are AmeriHealth Caritas DC and MedStar Family Choice DC, plus HSCSN for the SSI children's program, with Novitas Solutions for Medicare. On the commercial side, DISB's September 18, 2026 rate announcement says it reviewed filings from major carriers including CareFirst BlueCross BlueShield, Kaiser Permanente and UnitedHealthcare, across 181 health plans.

We give no market share figures because DISB's release has none. Our Kaiser Permanente billing guide covers one of those carriers. DC providers also see Maryland and Virginia plans, since many patients cross the border, so read the Maryland and Virginia rules when the plan is issued there.

How we handle billing in the District of Columbia

We start each DC claim by checking which of three clocks applies: the 365-day Medicaid limit, the one-calendar-year Medicare limit, or the plan's own window with the 180-day floor from § 31-3132(g). Medicaid claims are matched to the managed care plan in force on the date of service, which matters for any stay that spans the July 31, 2026 Wellpoint cutoff.

For underpaid out-of-network claims we run open negotiation and federal IDR from first notice to final payment, and we track the § 31-3132 interest for commercial claims paid late. Our hospital and facility billing team handles the institutional side. Book a call and we will review your DC payer mix first.