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

An enrollee’s physician forwards requests for services along with clinical information to MedStar Family Choice-DC, usually by phone or fax. Our experienced clinical staff reviews all requests.

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

MedStar Family Choice-DC makes decisions about services based upon whether or not the service is medically necessary and a covered benefit. We do not financially reward our providers, staff or anyone contracted with MedStar Family Choice-DC 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-DC has up to fourteen (14) days following the receipt of the request to process a non-pharmacy authorization request. Pharmacy requests will be processed within 72 hours of receipt of the request. Requests are considered complete when all necessary clinical information is received from the provider. An additional 14 days can be given to make a decision if it is requested by the enrollee or the provider, or if MedStar Family Choice-DC believes it is in the best interest of the enrollee.

 

This program is funded in part by the Government of the District of Columbia Department of Health Care Finance.
Information current as of: 09/17/20