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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 after hours 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 reserves the right to direct services to participating providers and facilities. Services outside the network are available only when they are not available within the network, for continuity reasons.

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. Retrospective services that could have been provided within the network are not likely to be retrospectively approved unless upon review the care was urgent/emergent or a continuity of care issue.

Pharmacy

MedStar Family Choice pays for a wide variety of medications, as outlined in our formulary. If a physician feels it medically necessary to prescribe a medication not on the 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 at (855) 210-6203, or fax requests to (202) 243-5496.

Requests for Synagis (palivizumab) require a completed Statement of Medical Necessity form and authorization is based on criteria set forth by the American Academy of Pediatrics Policy Statement.

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

In accordance with the Emergency Medical Treatment & Labor Act (EMTALA), MedStar Family Choice will pay claims for all medical screening examinations (MSE) when the request is made for examination or treatment for an emergency medical condition (EMC), including active labor. MedStar Family Choice does not consider a nurse exam or triage information as evidence of a medical screening exam.

In accordance with the Balanced Budget Act of 1997, MedStar Family Choice pays for emergency services using a prudent layperson standard. An "emergency medical condition" is defined as:

A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonable expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

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.

Substance Abuse

Admissions for alcohol or other substance abuse issues, even if admitted to a medical bed, are referred to Beacon Health Options, Substance Abuse or authorization and claims payment. ASAM utilization management criteria are used per plan benefit.

To request inpatient authorizations for substance abuse admissions to medical beds, the hospital utilization reviewer may contact Beacon Health Options, Substance Abuse directly by calling:1-866-702-9023, extension 292797 or extension 292592. The Utilization reviewer may also contact Beacon Health Options, Substance Abuse at 800-496-5849 to request authorizations. Providers may also access the Beacon Health Options website for additional information.

MedStar Family Choice Case Managers/utilization review staff are also available to assist the hospital utilization review staff with three-way calls to facilitate this process.

Beacon Health Options, Substance Abuse address for claims submission:
Beacon Health Options
PO Box 1850
Hicksville, NY 11802

Information current as of: 08/16/17