PCP referral requirement for in-network specialists
Customize your policy alerts
Sign up for all medstarfamilychoicedistrictofcolumbia policy alerts
Know when medstarfamilychoicedistrictofcolumbia releases new policies or updates existing guidance.
Monitor payer policy activity
Announces that MedStar Family Choice DC enrollees no longer need a PCP written referral to see in-network specialists; applies to MFC-DC providers and enrollees. Out-of-network specialist visits still require a written referral plus prior authorization.
A primary care physician (PCP) written referral to in-network specialists is no longer required for MedStar Family Choice DC enrollees effective October 1, 2024.
Referrals to out-of-network specialists still require a written referral and prior authorization.
Specialist Referral and Coverage Criteria
Specialist referral criteria
Referral and authorization stance for specialist visits:
Referral and Prior Authorization Requirements — Provider Actions
Referral and prior authorization requirements
Effective October 1, 2024, a PCP written referral is not required for MedStar Family Choice DC enrollees to see in-network specialists. For out-of-network specialist visits, providers must obtain a written referral and secure prior authorization using the MFC-DC Quick Prior Authorization Guide.
- In-network specialist visits: no PCP written referral required; submit claims as usual with necessary documentation.
- Out-of-network specialist visits: require a written referral and prior authorization—consult the MFC-DC Quick Prior Authorization Guide for services that need prior authorization.
Key Definitions: In-network vs Out-of-network Referrals
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.