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    v1.0.30
    OpenPayerPolicy UpdatesMedStar Family Choice, IncMedStar Family Choice Out-of-Network Update | Open…
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    CurrentMedStar Family Choice, MarylandPolicy 124

    Out-of-Network Services

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    This policy governs how MedStar Family Choice, Maryland handles requests for medically necessary services from out-of-network providers. It applies to utilization management staff, Medical Directors, case managers, referring providers, and out-of-network providers involved in these requests.

    Policy Summary
    PayerMedStar Family Choice, Maryland
    PolicyOut-of-Network Services
    Policy CodePolicy 124
    Change TypeClarified
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateNot specified
    Key ActionThe utilization management nurse must attempt redirection to an in-network provider before referring the request to the Medical Director.
    SourceLink
    POLICY UPDATE CHANGES

    Out-of-network benefit criteria and transition-of-care timeframes were clarified.

    The policy scope was updated to identify Maryland.

    The responsible departments and personnel titles were updated over successive reviews.

    Terminology was updated by replacing MFC with MedStar Family Choice and Case Manager with Utilization Management nurse.

    90 daysMaximum transition period
    $0Additional member charge

    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.

    Medical Director
    Individual review authority
    In-network firstRedirection before out-of-network care
    Not requiredCoverage outside the country

    Out-of-Network Coverage Criteria

    Authorization criteria for out-of-network services

    An out-of-network request may be authorized only when all of the following are met:

    ALL of the following

    • In-network redirection was attempted and was unsuccessful.
    • The Medical Director determines that the requested service is medically appropriate or medically necessary.
    • The requested service is not available from an in-network provider.

    Transition-of-care requirements

    Continuation of out-of-network treatment may be permitted during transition of care when all of the following requirements are met:

    ALL of the following

    • Treatment continues for the lesser of the current period of active treatment or up to 90 calendar days for a member undergoing treatment for a chronic or acute medical condition.Lesser of active-treatment period or up to 90 calendar days
    • The out-of-network provider agrees to continue treatment for an appropriate period based on transition-plan goals.
    • The provider shares treatment-plan information with MedStar Family Choice.
    • The provider follows MedStar Family Choice utilization management policies and procedures.
    • The provider accepts MedStar Family Choice payment terms.

    Denial or redirection criteria

    The request is subject to standard denial and/or redirection procedures if any of the following applies:

    ANY of the following

    • The requested service is not medically necessary.
    • The service can be handled by a network provider.
    • The request is beyond the applicable transition-of-care period.

    Member cost and geographic coverage

    Authorized medically necessary out-of-network services are subject to both of the following coverage conditions:

    ALL of the following

    • The out-of-network service is medically necessary and authorized.

      There is no additional charge to the member for authorized out-of-network services deemed medically necessary.

    • The service is rendered within the applicable coverage area.

      MedStar Family Choice is not required to cover services rendered out of the country.

    Transition-of-Care Timeframe

    Transition-of-Care Parameters
    Transition-of-care periodLesser of the current period of active treatment or up to 90 calendar days
    Applicable treatmentTreatment for a chronic or acute medical condition
    Member costNo charge for medically necessary authorized out-of-network services

    Out-of-Network Request Workflow

    Note

    Attempt In-Network Redirection

    The Utilization Management nurse receives the out-of-network request and contacts the referring provider to attempt redirection to an in-network provider. If redirection is successful, the nurse follows standard authorization procedures.

    Documentation Required

    Submit Clinical Information for Review

    When redirection is unsuccessful, the Utilization Management nurse gathers all necessary clinical information to support decision-making and sends the referral to the Medical Director through the Clinical Software System.

    Prior Authorization

    Individual Medical Director Review

    Every out-of-network request receives individual Medical Director review. Out-of-network services may be authorized case by case when the request is medically appropriate and the service is not available in-network.

    Key Terms

    Out-of-Network Request
    TermOut-of-network request
    DefinitionA request for a service from a provider who is not in the MedStar Family Choice network
    Review standardAll out-of-network requests are reviewed individually by the Medical Director
    Transition of Care
    TermTransition of care
    DefinitionContinuation of treatment for the lesser of the current active-treatment period or up to 90 calendar days for a member being treated for a chronic or acute medical condition
    Provider requirement
    Policy Summary
    PayerMedStar Family Choice, Maryland
    PolicyOut-of-Network Services
    Policy CodePolicy 124
    Change TypeClarified
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateNot specified
    Key ActionThe utilization management nurse must attempt redirection to an in-network provider before referring the request to the Medical Director.
    SourceLink
    On This Page
    Out-of-Network Coverage CriteriaTransition-of-Care TimeframeOut-of-Network Request WorkflowKey Terms
    • Continuation of treatment may continue for the lesser of the current period of active treatment or up to a 90-calendar-day transition period for members undergoing treatment for a chronic or acute medical condition.
    • There is no additional charge to the member for out-of-network services deemed medically necessary.
    Prior Authorization

    Complete Authorization and Secure Provider Agreement

    If the Medical Director approves the request, the case manager completes the authorization. The out-of-network provider must agree to continue treatment for an appropriate period based on transition-plan goals, share treatment-plan information with MedStar Family Choice, follow its Utilization Management policies and procedures, and accept MedStar Family Choice payment terms.

    Denial Risk

    Denial or Redirection When Criteria Are Not Met

    If the Medical Director determines that the request is not medically necessary, can be handled by a network provider, or falls beyond the applicable transition-of-care period, the Utilization Management nurse follows the standard process for denial and/or redirection.

    Billing Rule

    Negotiate Alternate Fee Agreement When Needed

    MedStar Family Choice completes a fee agreement with the out-of-network provider when needed, including when the provider will not accept the Medicaid fee schedule and an alternate fee must be negotiated.

    Documentation Required

    Document in Clinical Software System

    All documentation related to the out-of-network request must be recorded in the Clinical Software System.

    The out-of-network provider must agree to continue treatment for an appropriate period based on transition-plan goals