Utilization review and pharmacy prior authorization reporting
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This document provides aggregated requirements and performance metrics for prior authorization requests and appeals for MedStar Family Choice District of Columbia affecting relevant providers (e.g., Family Medicine, Pediatrics, Obstetrics/Gynecology, Emergency Medicine, Registered Pharmacists).
No material clinical or coverage changes in this revision.
Coverage stance and summary
Coverage stance summary
Document lists categories of non-covered items and authorization barriers but does not provide detailed coverage criteria. Coverage is informational and identifies common reasons for adverse determinations and prior authorization barriers.
Common reasons for adverse determinations or PA barriers (ONE or more may apply):
- PA requirements not met
- Non Formulary
- Authorization/Access Restrictions
- Non-covered Medicine (e.g., Fertility, ED, Cosmetic)
- Quantity over Limit
- Refill too soon
- Non-covered Service
- Requested Information Not Received
- Out of Network
- Not Medically Necessary
- Administrative Denial
- Brand Not Medically Necessary
- Not on the Fee Schedule
- Not MCO Liability
- Not FDA approved
Coding and turnaround metrics
| No codes listed |
Prior authorization requirements and reasons for adverse determinations
Prior authorization must meet requirements and include requested information; common denial reasons listed
Prior authorization (PA) requests may be denied for specific, listed reasons; providers must ensure submitted PAs meet all requirements and include requested information to avoid adverse determinations. Common denial causes include: PA requirements not met; Non Formulary; Authorization/Access Restrictions; Non-covered Medicine (e.g., Fertility, ED, Cosmetic); Quantity over Limit; Refill too soon; Non-covered Service; Requested Information Not Received; Out of Network; Not Medically Necessary; Administrative Denial; Brand Not Medically Necessary; Not on the Fee Schedule; Not MCO Liability; Not FDA approved.
- Verify PA requirements are met before submission to reduce risk of denial for “PA requirements not met.”
- Include all requested supporting information to prevent “Requested Information Not Received” administrative denials.
- Confirm the drug or service is on-formulary and covered (not listed as Non Formulary or Non-covered Medicine/Service).
- Check quantity limits and refill timing to avoid “Quantity over Limit” or “Refill too soon” denials.
- Ensure the patient is in-network and the service is within MCO liability and FDA-approved indications when applicable.
Adverse determination reasons (examples)
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