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Preauthorization and Utilization Management

All criteria utilized in utilization management are available upon request. The request can be made independent of a specific case. Reviewers and Medical Directors are also available to discuss any and all utilization management decisions, questions or issues. To request specific utilization management criteria or to speak with a MedStar Family Choice Reviewer or Medical Director please contact us during our normal business hours, 8:00 a.m.to 5:30 p.m. at 855-210-6203 or 202-243-5400. The fax number is 202-243-5495 or 202-243-5496. Messages received outside of normal business hours will be addressed the following business day.

Pre-Authorization

MedStar Family Choice follows a basic pre-authorization process: A member's physician forwards clinical information and requests for services to MedStar Family Choice by phone, fax or infrequently by mail. You may contact a case manager on business days from 8:00 a.m.to 5:30 p.m. at 855-210-6203 or 202-243-5400. Our fax number is 202-243-5495 or 202-243-5496 and faxes are received 24 hours a day, 7 days a week. Faxes and voice messages received after hours will be addressed the next business day. The afterhours voice mail message includes name and telephone number to contact for after hours needs. The message also contains a telephone number for a MedStar Family Choice representative to be contacted for urgent medical and pharmacy issues.

All appropriate ICD-10/CPT/HCPCS, along with supporting clinical information must be included in requests for pre-authorization. Requests for authorization can be included on the Uniform Consultation Referral Form or Prior Authorization (Non-Pharmacy) Request Form with clinical information attached. Our experienced clinical staff reviews all requests. MedStar Family Choice pre-authorization decisions are based on the following criteria:

  • MedStar Family Choice Protocols
  • MedStar Family Choice Pharmacy Policies and Procedures
  • InterQual
  • Medicare and Medicaid Guidelines
  • District of Columbia regulations and contract requirements
  • MedStar Family Choice Managed Care Organization benefit coverage
  • MedStar Family Choice Provider Manual
  • MedStar Family Choice Member Handbook
  • FDA Approval
  • District of Columbia DMS/DME Program Approved List of Items
  • Availability of services within the MedStar Family Choice network
  • MedStar Family Choice Continuity of Care Policy
  • UM Criteria Policy

MedStar Family Choice's utilization management decision making is based on the medical necessity of the service and the existence of Managed Care Organization enrollment and coverage.

MedStar Family Choice requires is allowed up to fourteen (14) days to process a complete, non-urgent authorization request. Requests are considered complete when all necessary clinical information is received from the requesting provider. MedStar Family Choice can take an additional 14 days to make a final decision if the provider or member requests the extension or if MedStar Family Choice determines an extension is in the best interest of the member. If the service requested is denied the provider may contact our Care Management Department to discuss the decision with the appropriate physician advisor.

A limited number of services require authorization from MedStar Family Choice Care Management before the patient receives care. The list is included in the MedStar Family Choice Provider Manual.

Retrospective requests are reviewed against the above specified criteria and are not guaranteed for approval.

Pharmacy

DC Healthcare Alliance members have their medications filled at participating Alliance pharmacies. The DC Healthcare Alliance formulary is listed on the MedStar Family Choice website. If a physician feels it is medically necessary to prescribe a medication not on the Alliance formulary, the physician may submit this request to MedStar Family Choice. Such a request must include clinical documentation that supports the medical need for that specific medication. All non-formulary requests are reviewed by a physician advisor. MedStar Family Choice does not guarantee coverage of medications, which are outside the guidelines set forth in the manual. Physicians may call MedStar Family Choice Care Management at (888) 210-6203 or fax the request to (202) 243-5496.

Concurrent Review

MedStar Family Choice utilizes the following criteria to make concurrent review decisions:

  • InterQual
  • Medicare and Medicaid Guidelines
  • District of Columbia regulations or contract requirements
  • MedStar Family Choice benefit coverage
  • Availability of services within the MedStar Family Choice network

MedStar Family Choice reviews clinical documentation for timeliness of care and appropriate level of care. Clinical denial determinations may be issued by our physician advisors when a delay in care or delay in discharge planning creates an inpatient day that could have been avoided if service had been provided timely.

While MedStar Family Choice care managers are available to assist with discharge planning, it is the responsibility of the inpatient facility to provide timely and appropriate discharge planning. Inpatient days that do not meet medical necessity as outlined in above criteria are the responsibility of the inpatient facility.

Emergency Care

Many emergency serves are covered by DC Healthcare Alliance. Hospital Claims for emergency services should be submitted to DC Healthcare Alliance prior to submitting to MedStar Family Choice.

MedStar Family Choice requires and fully reviews emergency department clinical documentation for evidence of a medical screening exam, prudent layperson guidelines, as well as evaluation of assigned treatment levels based on reasonable clinical care time guidelines.

MedStar Family Choice Decision Making

MedStar Family Choice does not specifically reward practitioners or other individuals for issuing denials of coverage of care. In addition, there are no financial incentives for UM decision makers that would encourage decisions that result in underutilization. Clinical practice guidelines for certain conditions can be found on the website. Providers may also call the MedStar Family Choice Care Management Department to request a written copy. Providers may request the UM criteria utilized for a specific case by calling the MedStar Family Choice Care Management Department at (855) 210-6203.

For members with urgent authorization needs, physicians or a physician’s staff member should contact MedStar Family Choice Care Management at (855) 210-6203. A decision regarding urgent authorizations will be made within 24 hours of receiving the request.

Information current as of: 08/02/17