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Provider Manual

Important Notice: As of October 1, 2017, the MedStar Family Choice contract to provide Medicaid services to residents in the District of Columbia has ended. Learn more >

The MedStar Family Choice Provider Manual advises you about the MedStar Family Choice Managed Care Organization, including its policies and procedures relative to providing care. It also contains useful contact information to assist our network providers and their staffs. Read an introduction to the manual.

If you would like, you may download a PDF version of the entire manual version of the entire manual. The provider manual can be viewed by specific chapters and sections.

I. GENERAL INFORMATION

  • WELCOME TO MEDSTAR FAMILY CHOICE
  • DC HEALTHY FAMILIES AND DC HEALTHCARE ALLIANCE PROGRAMS
  • MEDSTAR FAMILY CHOICE WEBSITE
  • MEMBER RIGHTS AND RESPONSIBILITIES
  • ANTI-GAG PROVISIONS
  • ASSIGNMENT AND REASSIGNMENT OF A MEMBER
  • PRIMARY CARE PHYSICIAN SELECTION
  • BECOMING A PROVIDER
    • Initial Credentialing
    • Recredentialing
  • PROVIDER TRAINING
  • PROVIDER REIMBURSEMENT
    • Self-Referred and Emergency Services
    • Out of Network Providers for Services
    • Second Opinions
    • Members with Special Healthcare Needs
  • CONTRACT TERMINATIONS
    • Primary Care Providers
    • Specialist Providers
  • CONTINUITY OF CARE
  • SPECIALTY REFERRALS
  • TRANSPORTATION

II. PROVIDER RESPONSIBILITIES

  • ROLE AND RESPONSIBILITIES OF PRIMARY CARE PROVIDERS
  • ROLE AND RESPONSIBILITIES OF SPECIALIST PROVIDERS
  • CLINICS AS PROVIDERS
  • IDEA SERVICE PROVIDERS
  • ROLE AND RESPONSBILITIES OF OB/GYN PROVIDERS
    • Routine Care
    • High Risk OB Patients
    • Home Visiting Outreach for High Risk Newborns
  • REPORTING COMMUNICABLE DISEASE
  • APPOINTMENT SCHEDULING
    • Initial Health Appointment for Adult and Pregnant Members
    • Wellness Services for Children Under 21 years
    • Individual with Disabilities Education Act (IDEA)
    • EPSDT Outreach
    • Services for Pregnant and Post Partum Women
      • Childbirth Related Provisions
      • Home Visiting for High Risk Newborns
  • SPECIAL NEEDS POPULATIONS
    • Services Every Special Needs Population Receives
    • Special Populations-Outreach

III. MEDSTAR FAMILY CHOICE CARE MANAGEMENT AND CLAIMS

  • OVERVIEW
  • OUTREACH SERVICES
    • New Members
    • Non-Compliant Members
  • CASE MANAGEMENT AND DISEASE MANAGEMENT
    • Complex Case Management
    • Disease Management
  • HEALTH EDUCATION
  • EPSDT EDUCATION
  • INTERPRETER SERVICES
  • ELIGIBILITY VERIFICATION
  • REFERRAL AND UTILIZATION MANAGEMENT PROCESS
    • Routine Referrals
    • Behavioral Health Services
    • Dental Services
    • Laboratory Referrals
    • OB/GYN Referrals
    • Radiology Referrals
    • Rehabilitation Referrals
    • Vision
    • Urgent/Emergent Referrals
    • Utilization Management (Pre-Authorization)
      • Pharmacy
        • Denial of Prescription Drugs
      • Concurrent Review
      • Emergency Care
      • Services Requiring Prior-Authorization
      • Injectables and Non-Formulary Meds requiring Prior Authorization
      • New Technolog
  • CLAIMS
    • Submitting Claims
    • Claims Appeal Process
    • ER Auto-Pay List
    • Overpayments-Refunds

IV. BENEFITS AND SERVICES

  • OVERVIEW
  • COVERED BENEFITS AND SERVICES DC Healthy Families
    • Covered Benefits 21 Years and Older
    • Covered Services for Under 21 years (EPSDT)
      • Screening and Assessment Services
      • Diagnostic and Treatment Services
      • Informing, Scheduling, and Transportation
    • Covered Behavioral Health Services
    • Special Rules Regarding Coverage of services for Infants, Toddlers, Preschool-Age children and School-Age Children and Youth
    • Covered Services Not Covered BY MFC But Provided by DC Medicaid
    • Excluded Dental Services for individuals age 21 and older
  • COVERED SERVICES FOR DC HEALTHCARE ALLIANCE
    • Coverage Exclusions under the Alliance Program
  • COVERAGE OF INPATIENT SERVICES AT TIME OF ENROLLMENT
  • EXCLUDED SERVICES
  • HEALTHCARE ACQUIRED CONDITIONS
  • NEVER EVENTS

V. QUALITY IMPROVEMENT AND MFC OVERSIGHT ACTIVITITIES

  • QUALITY IMPROVEMENT PROGRAM
    • Provider Role in Quality Management
    • Medical Records Requirements
    • Additional Information
    • Critical Incidents, Sentinel Events and Never Events
    • Never Events and Health Care Acquired Conditions
  • MFC COMPLIANCE PROGRAM
    • Fraud, Waste and Abuse
    • HIPAA
  • GRIEVANCES AND APPEALS REPORTING
    • MedStar Family Choice Member Hotline
    • MedStar Family Choice Member Grievance/Appeal Policy and Procedure
      • Member Internal Grievance Procedure
      • Second Level Grievance Review Process
    • Medical Coverage Appeal Process for Members
      • Urgent Appeals
      • Non-urgent Appeals
      • District Fair Hearings
    • MedStar Family Choice Provider Grievance/Appeal Process
Information current as of: 10/13/17