Preauthorization and Utilization Management

Prior authorization

MedStar Family Choice DC follows a basic prior-authorization process: Requests for services are accepted by phone, fax or by mail. You may contact us on business days from 8 a.m.to 5:30 p.m. at 855-798-4244 or 202-363-4348. Submit your requests along with necessary medical records/clinical information for the date of service to the number indicated on the specific authorization request form. Faxes are received 24 hours a day, 7 days a week. Faxes and voice messages received after business hours will be addressed the next business day. The after-hours voice mail message includes contact information for our after-hours representative, who will assist you with urgent pharmacy issues. 

All appropriate ICD-10/CPT/HCPCS, along with supporting clinical information, must be included with requests for prior-authorization.

• For Non-Pharmacy requests, use the Prior Authorization (Non-Pharmacy & DME) Request Form or Uniform Consultation Referral Form, and fax to us at 202-243-6307.

• For Personal Care Aide (PCA) requests, submit the electronic prescriber order form (ePOF) along with any necessary medical records/clinical information or the date of service via Department of Health Care Finance (DHCF) portal. Please submit ePOF requests for recertification at least 3 months prior to expiration of current authorization. 

Our experienced clinical staff reviews all requests requiring prior authorization. MedStar Family Choice DC prior-authorization decisions are based on the following criteria:

• MedStar Family Choice DC Pharmacy Policies and Procedures

• InterQual or ASAM guidelines

• Medicare and Medicaid Guidelines

• District of Columbia regulations and contract requirements

• MedStar Family Choice DC Managed Care Plan benefit coverage 

• FDA Approval

• District of Columbia DMS/DME Program Approved List of Items

• Availability of services within the MedStar Family Choice DC network

• MedStar Family Choice DC Continuity of Care Policy

• UM Criteria Policy

MedStar Family Choice DC reserves the right to direct services to participating providers and facilities. Services outside the network are allowed only when they are not available within the network, or for continuity of care reasons.

MedStar Family Choice DC'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 DC allows up to fourteen (14) days to process non-urgent authorization requests. MedStar Family Choice DC can take an additional 14 days to make a final decision if the provider or enrollee requests an extension or if MedStar Family Choice DC determines an extension is in the best interest of the Enrollee. If the service requested is denied, information on how to request an Appeal is included in the denial letter.

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

For Pharmacy requests, MedStar Family Choice DC must make a decision within 24-hours of receipt of the request. Please ensure that all pertinent clinical information is provided with the request to prevent any denial of service for lack of clinical information. 

MedStar Family Choice DC 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 DC for prior authorization. Such a request must include clinical documentation that supports the medical need for that specific medication. All non-formulary requests are reviewed by a Medical Director. MedStar Family Choice DC does not guarantee coverage of medications, that are outside the guidelines set forth in the manual. Physicians may call MedStar Family Choice DC at 855-798-4244. Fax your requests to 202-243-6258. 

Inpatient (Concurrent review) Authorization

• InterQual and ASAM

• Medicare and Medicaid Guidelines

• District of Columbia regulations or contract requirements

• MedStar Family Choice DC benefit coverage

• Availability of services within the MedStar Family Choice DC network

MedStar Family Choice DC reviews clinical documentation for timeliness of care and appropriate level of care. Clinical denial determinations may be issued by our Medical Director 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 DC 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.

For Inpatient Concurrent Reviews, fax your requests along with necessary medical records/clinicals for the date of service to 202-243-6256.