Utilization Management (UM) Criteria — Clinical Operations
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Defines MedStar Family Choice District of Columbia's utilization management criteria, processes, and timelines for prior authorization, concurrent review, pharmacy, emergency care, and related UM workflows; applicable to providers submitting authorization and retrospective requests for MedStar Family Choice DC enrollees.
Updated timeliness of prior authorization decisions.
Added the District of Columbia's Prior Authorization Reform Amendment Act of 2023 to regulatory references.
Clarified that medical and behavioral health prior-authorization decisions use comparable evidentiary standards and are no more stringent for behavioral health.
Added contract reference section C.5.30.9.2.3.
Changed Assistant Vice President of Clinical Operations title to Director of Clinical Operations.
Coverage and Medical Necessity Criteria
General UM coverage criteria
Covered when ALL of the following are met:
Based on MedStar protocols, pharmacy policies, InterQual/ASAM, Medicare/Medicaid, DHCF contract, FDA approval, network availability, continuity of care
Faxes are received 24 hours/day, 7 days/week; telephones manned business days 8:00am-5:30pm; requests can use MedStar Prior Authorization Form or Uniform Consultation Referral Form
Prior authorization decisions processed as expeditiously as clinical situation warrants; extensions allowed per policy
Examples include services carved out to DC agencies (behavioral health for Alliance, some SUD services) and DHCF/ADAP-covered medications
Services that are the financial responsibility of other District of Columbia agencies are carved out of MedStar Family Choice DC coverage and may be administratively denied. Examples include behavioral health services administered by the Department of Behavioral Health, medications covered by DHCF or the AIDS Drug Assistance Program (ADAP), and Emergency Medicaid services for DC Healthcare Alliance enrollees. Providers should not assume MedStar Family Choice DC liability for these items and must direct eligibility and payment inquiries to the responsible DC agency when applicable.
Medications included on other agency formularies or ADAP are not covered by the MedStar Family Choice DC Managed Care Plan and requests for such items are subject to administrative denial. For non‑formulary or otherwise excluded medications, practitioners may submit a non‑formulary request with clinical documentation supporting medical necessity and prior use of formulary alternatives; all non‑formulary requests are reviewed by the Health Plan Pharmacist or a Medical Director per the plan's pharmacy procedures.
Ongoing services or treatments that, upon review, do not demonstrate improvement in the enrollee’s condition or benefit to the enrollee may be denied as not medically necessary. Retrospective requests for services that could have been provided within the network are likewise unlikely to be approved unless the review documents that the care was urgent/emergent or there was a continuity‑of‑care issue.
Required Coding on Requests
| ICD-10 | All appropriate ICD-10 diagnosis codes must be included with requests |
| CPT | All appropriate CPT procedure codes must be included with requests |
| HCPCS | All appropriate HCPCS codes must be included with requests |
Provider Requirements, Timelines, and Authorization Processes
Prior authorization: which services, how to submit, and decision timelines
Prior authorization is required only for a limited set of services listed in the MedStar Family Choice DC Provider Manual and Quick Authorization Guide; providers must submit clinical information (most often via eFax, but telephone, secure email, or mail are also accepted) and adhere to decision timelines (standard decisions no later than 5 business days; concurrent/urgent decisions no later than 72 hours). Phones are staffed business days 8:00am–5:30pm and fax lines accept requests 24/7 (pharmacy fax 202-243-6258; non-pharmacy 202-243-6307; behavioral health 202-243-6320).
- Submit requests using the MedStar Family Choice DC Prior Authorization Form or a Uniform Consultation Referral Form with clinical attachments when applicable.
- Use fax for most requests (pharmacy: 202-243-6258; non-pharmacy: 202-243-6307; behavioral health: 202-243-6320).
- Telephone numbers: 1-(855)-798-4244 or (202)-363-4348 (staffed business days 8:00am–5:30pm).
Non‑formulary medication requests: required documentation and review
When prescribing a non-formulary medication, the practitioner must submit clinical documentation that supports the medical need for that specific medication and any prior use of available formulary medications, when applicable; all non‑formulary requests are reviewed by the Health Plan Pharmacist or a Medical Director.
- Include prior trials of formulary agents and supporting clinical notes in the request.
- Submit non-formulary prior authorization requests by fax (202-243-6258) or phone (1-855-798-4244 or 202-363-4348) using the Prior Authorization form and follow pharmacy guidance on the website.
- Certain drugs (e.g., Synagis, Hepatitis C therapies) require specific completed forms found on the MedStar Family Choice DC website.
Provider documentation and coding required on PA requests
Include all appropriate ICD-10, CPT, and HCPCS codes plus supporting clinical information with prior authorization requests; requests may use the MedStar Family Choice DC Prior Authorization Form or a Uniform Consultation Referral Form with clinical attachments.
- Provide diagnosis codes (ICD-10), procedure codes (CPT), and any relevant HCPCS codes on the request.
- Attach clinical records, test results, and rationale tying codes to medical necessity per MedStar protocols and referenced guidelines.
Retrospective requests: when approval is unlikely and required documentation
Retrospective requests are reviewed against the same criteria as pre‑service requests and are unlikely to be approved if the service could have been provided within the network unless the care was urgent/emergent or a continuity‑of‑care issue is demonstrated; services carved out to other DC agencies are administratively denied.
- Document urgency/emergent status or network access/continuity issues when submitting retrospective requests to support approval.
- Do not expect retrospective approval for services that are the responsibility of another DC agency (e.g., DHCF or ADAP-covered medications).
Key Definitions
Policy Background and Decision Framework
MedStar Family Choice DC bases utilization management decisions on medical necessity and applicable coverage rules, using established protocols and external guidance such as pharmacy policies, InterQual/ASAM criteria, Medicare/Medicaid rules, and professional society guidelines. Decisions apply consistently across medical and behavioral health services and account for network availability and continuity of care.
Prior authorization is required for a defined set of services listed in the Provider Manual/Quick Authorization Guide; requests must include all relevant diagnosis and procedure codes and supporting clinical information and may be submitted via the plan’s authorized channels (including 24/7 fax). The plan adheres to stated decision timelines (standard requests: no more than 5 business days; urgent/concurrent: 72 hours), and pharmacy pre‑service and concurrent authorizations are completed within 24 hours where applicable.
Retrospective requests are reviewed against the same medical necessity and coverage criteria but are not guaranteed approval. Services carved out to other DC agencies, medications covered by DHCF or ADAP, and claims where the submitted claim does not match the clinical documentation are subject to administrative denial. The plan’s pharmacy procedures require that non‑formulary medication requests include clinical justification and prior formulary use and are reviewed by the Health Plan Pharmacist or Medical Director.
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