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Utilization Management

To ensure that members receive the most appropriate healthcare, MedStar Family Choice follows a basic pre-authorization process:

A member’s physician forwards requests for services and clinical information to MedStar Family Choice, usually by phone or fax. Our experienced clinical staff reviews all requests.

MedStar Family Choice pre-authorization decisions are based on nationally recognized criteria, such as InterQual, and Medicare guidelines. Member needs that fall outside of standard criteria are reviewed by our physician staff for plan coverage and medical necessity.

MedStar Family Choice approves or denies services based upon whether or not the service is medically needed and a covered benefit. We do not financially reward our providers, staff or anyone contracted with MedStar Family Choice for denying services. In addition, we do not financially reward anyone involved in the decision process in such a way that would encourage less use of services.

MedStar Family Choice requires up to two business days to process a complete authorization request. Requests are considered complete when all necessary clinical information is received from the provider. The final decision cannot take longer than seven days, whether or not all clinical information has been received.

Questions about Utilization Management Issues

If you have questions about utilization management issues, please call our Member Services Department at 1-888-404-3549. We are available Monday to Friday, from 8:30 a.m. to 5:00 p.m. Any voice messages received outside of normal business hours will be addressed the next business day.

If you are deaf or have trouble hearing a TTY line is available at 1-800-508-6975. In addition, members may access Maryland Relay Service.

If you do not speak English, you may contact Member Services toll free at 1-888-404-3549 to request assistant through an interpreter. This service is available to you free of charge.

Information current as of: 09/13/17