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Timeliness of UM Decisions

MedStar Family Choice is an accredited MCO through NCQA (National Committee for Quality Assurance). As such, we follow standards set forth by NCQA or DHMH, whichever is stricter.

Effective April 10th, 2014, in accordance with NCQA Standard UM 5, Timeliness of UM Decisions, MedStar Family choice will follow the following timeframes:

Initial Request for Inpatient Authorization

In situations where MFC receives requests for inpatient authorization accompanied by clinical review, MFC will communicate a decision within 24 hours (1 calendar day) of receipt of your request.

In situations where initial inpatient authorization requests are NOT accompanied by clinical review, it is MFC's process to make one attempt within the first 24 hours (1 calendar day) following receipt of authorization request to request clinical information. If unable to obtain the necessary clinical information within the initial 24 hours after the receipt of the authorization request, the inpatient admission will be subject to denial for lack of clinical information.

Concurrent Review

In situations where MFC receives requests for additional urgent concurrent care that is accompanied by clinical review, MFC will communicate a decision within 24 hours (1 calendar day) of receipt of your request.

In situations where MFC receives requests for additional urgent concurrent care that is NOT accompanied by clinical review it is MFC's process to make at least one attempt to request the outstanding clinical information. Clinical not received within 24 hours (1 calendar day) of the authorization request will be subject to denial.

Information current as of: 11/09/15