District of Columbia - Occupational Therapy Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

The District of Columbia Department of Health (DC Health) Board of Occupational Therapy licenses Occupational Therapists, while the Department of Health Care Finance (DHCF) and the Department on Disability Services (DDS) jointly approve providers to bill for Home and Community-Based Services (HCBS) waiver services. To deliver Occupational Therapy under the HCBS Waiver for Persons with Intellectual and Developmental Disabilities (IDD), an applicant must first pass the DDS Provider Certification Review (PCR) process before submitting a Medicaid enrollment application.

Approval requires holding an active DC Health OT license, securing a National Provider Identifier (NPI), and completing the DHCF Provider Data Management System (PDMS) enrollment. Independent therapists must either enroll as individual fee-for-service providers or contract with an existing DDS-approved Home Health Agency or waiver provider organization to render services to waiver participants.

1. Service Definition and Scope

In the District of Columbia, Occupational Therapy under the HCBS IDD and EPD waivers consists of evaluation and therapeutic interventions designed to restore, develop, or maintain a beneficiary's ability to perform activities of daily living (ADLs). Services must be prescribed by a physician and incorporated into the participant's Individualized Service Plan (ISP) or Person-Centered Plan (PCP).

Interventions focus on fine motor skills, sensory integration, and environmental adaptations to maximize independence in the community.

• Scope of Practice: Defined by the DC Health Occupations Revision Act, encompassing therapeutic use of everyday life activities.
• Waiver Coverage: Funded through the DHCF HCBS IDD Waiver and EPD Waiver programs.
• Service Setting: Delivered in the participant's home, day habilitation center, or community environments.
• Prescription Requirement: Requires a valid physician's order or referral prior to evaluation and treatment.
• Plan of Care: Interventions must align with the DDS-approved Individualized Service Plan (ISP).

2. Regulatory and Oversight Agencies

The DC Board of Occupational Therapy, under DC Health's Health Regulation and Licensing Administration (HRLA), issues professional licenses. The Department of Health Care Finance (DHCF) serves as the State Medicaid Agency, managing provider enrollment and claims.

The Department on Disability Services (DDS) oversees the programmatic elements of the IDD waiver, including provider certification and quality assurance.

• DC Board of Occupational Therapy: Licenses OTs and OTAs (https://dchealth.dc.gov/node/146292).
• Department of Health Care Finance (DHCF): Administers the DC Medicaid program and MMIS (https://dhcf.dc.gov).
• Department on Disability Services (DDS): Operates the HCBS IDD Waiver and conducts Provider Certification Reviews (https://dds.dc.gov).
• Maximus / DC Medicaid Provider Portal: Manages the Provider Data Management System (PDMS) for enrollment (https://www.dc-medicaid.com).

3. Gatekeeping Prerequisites: Who Can Even Apply

The District of Columbia does not require a Certificate of Need (CON) for independent occupational therapy practices. However, to bill the HCBS IDD Waiver directly, a provider must first obtain a DDS Provider Certification Review (PCR) approval.

Without this DDS certification, DHCF will reject the Medicaid enrollment application for waiver-specific taxonomy codes.

• DDS Certification: HCBS IDD waiver providers must pass the DDS Provider Certification Review (PCR) before DHCF Medicaid enrollment.
• NPI Requirement: Applicants must obtain a Type 1 (Individual) or Type 2 (Organization) National Provider Identifier prior to application.
• Business Licensure: Corporate entities must hold a Basic Business License (BBL) from the DC Department of Licensing and Consumer Protection (DLCP).
• Medicaid Screening: Subject to DHCF risk-based screening; physical therapy and occupational therapy are generally categorized as limited or moderate risk.

4. Licensure and Certification Requirements

DC Health requires all OTs to graduate from an ACOTE-accredited program and pass the NBCOT examination. Applicants must submit their application via the DC Health online licensing portal with required documentation and fees.

Pursuant to D.C. Code Section 2-3305.5, applicants must provide a Social Security Number to process the professional license.

• Education: Degree from an Accreditation Council for Occupational Therapy Education (ACOTE) accredited program.
• Examination: Passing score on the National Board for Certification in Occupational Therapy (NBCOT) exam.
• Application Fee: $264 initial licensure fee paid to DC Health.
• Background Check: Mandatory fingerprint-based Criminal Background Check (CBC) through the DC Metropolitan Police Department or approved vendor.
• Identification: Social Security Number required pursuant to D.C. Code Section 2-3305.5.

5. Medicaid Provider Enrollment

Enrollment is processed through the DHCF Provider Data Management System (PDMS), managed by Maximus. Providers must submit proof of DC Health licensure, DDS certification (if applicable), and liability insurance.

Providers must complete the DHCF Provider Agreement and set up Electronic Funds Transfer (EFT) for claims payment.

• Enrollment Portal: Applications submitted via the DC Medicaid Web Portal (https://www.dc-medicaid.com).
• Application Fee: Subject to the ACA Medicaid provider application fee unless enrolled in Medicare or paying the fee to another state.
• Required Forms: W-9, Electronic Funds Transfer (EFT) authorization, and DHCF Provider Agreement.
• Revalidation: Providers must revalidate their Medicaid enrollment every three to five years depending on risk category.

6. Staffing, Training and Background Checks

Licensed OTs must maintain active credentials and complete continuing education to renew their DC Health license. Agencies employing OTs must ensure all staff interacting with waiver participants pass rigorous background screenings.

Supervision rules dictate that Occupational Therapy Assistants (OTAs) must practice under the direction of a fully licensed OT.

• Continuing Education: DC Health requires 24 hours of approved continuing education every two years for license renewal.
• CPR Certification: Must maintain current, hands-on CPR and First Aid certification.
• Background Screening: Annual checks against the DC Child and Family Services Agency (CFSA) Child Protection Register and Medicaid Exclusion lists (OIG LEIE).
• Supervision: Occupational Therapy Assistants (OTAs) must practice under the direct or general supervision of a licensed OT as defined by DC municipal regulations.

7. Documentation, Policies and Records

DHCF and DDS require meticulous clinical and financial record-keeping. Providers must document every encounter, ensuring notes align with the authorized Individualized Service Plan (ISP) and physician orders.

Records must be made available to DHCF, DDS, or CMS auditors upon request.

• Clinical Notes: Must include date, start/stop times, specific interventions, participant response, and therapist signature.
• Record Retention: DC Medicaid requires providers to retain all financial and medical records for a minimum of ten years.
• Incident Reporting: Mandatory reporting of critical incidents to DDS via the MCIS (Management and Clinical Information System) within 24 hours.
• HIPAA Compliance: Must maintain written policies for safeguarding Protected Health Information (PHI) in accordance with federal and district laws.

8. Billing, Rates and Claims

Claims are submitted electronically to the DHCF MMIS using standard HIPAA-compliant 837P formats. Reimbursement rates for HCBS waiver services are established by DHCF and published in the Medicaid fee schedule.

Services cannot be billed until a Service Authorization (SA) is approved in the system.

• Billing System: Claims processed through the DC Medicaid Web Portal / MMIS.
• Procedure Codes: Typically billed using CPT codes such as 97165 (OT Eval) and 97530 (Therapeutic Activities), subject to waiver-specific modifiers.
• Prior Authorization: Waiver services require an approved Service Authorization (SA) generated from the DDS-approved ISP before billing.
• Timely Filing: Claims must be submitted within 365 days of the date of service to be eligible for DHCF reimbursement.

9. Approval Sequence and Timeline

The end-to-end process for becoming a fully enrolled HCBS OT provider in DC spans several months. It begins with professional licensure and culminates in Medicaid portal approval.

Delays in background checks or DDS certification reviews will extend the timeline.

• Step 1: Obtain DC Health OT license (typically 4-8 weeks after submitting all documents and CBC).
• Step 2: Secure NPI and DC Basic Business License (1-2 weeks).
• Step 3: Complete DDS Provider Certification Review for HCBS waiver participation (3-6 months).
• Step 4: Submit DHCF Medicaid enrollment via PDMS (30-60 days for processing).

10. Common Denials and Survey Findings

Applications and claims are frequently delayed or denied due to administrative errors or missing documentation. DDS and DHCF audits often target discrepancies between billed time and clinical documentation.

Failure to maintain an active DC Health license will result in immediate suspension of Medicaid billing privileges.

• Licensure Lapses: Denials due to expired DC Health licenses or failure to report address changes.
• Missing Signatures: Recoupment of funds during audits for missing physician signatures on the plan of care.
• Unauthorized Services: Billing for services before the Service Authorization (SA) is officially approved in the MMIS.
• Incomplete Background Checks: Failure to complete the mandatory fingerprint CBC or OIG exclusion checks prior to rendering services.

11. Key Contacts and Resources

Providers should utilize the official DC government portals for the most current regulations, fee schedules, and provider manuals. The Maximus help desk is the primary contact for PDMS enrollment issues.

For waiver-specific programmatic questions, providers should contact the DDS Medicaid Waiver Unit.

• DC Board of Occupational Therapy: https://dchealth.dc.gov/node/146292
• Department of Health Care Finance (DHCF): https://dhcf.dc.gov
• Department on Disability Services (DDS): https://dds.dc.gov
• DC Medicaid Provider Portal (Maximus): https://www.dc-medicaid.com
• DC Health Background Check Information: https://dchealth.dc.gov/node/120532

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