Preauthorization and Utilization Management

All criteria applied in utilization management are available upon request. The request can be made independent of a specific case. Reviewers or 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-DC Reviewer or Medical Director please contact us during our normal business hours (8:00 a.m.to 5:30 p.m.) at 202-362-1393. Messages received outside of normal business hours will be addressed the following business day.

Prior-Authorization

MedStar Family Choice-DC follows a basic pre-authorization process: Requests for services are accepted by phone, fax or by mail. You may contact us on business days from 8:00 a.m.to 5:30 p.m. at 855-798-4244 or 202-363-4348. Our fax number is 202-362-1393 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 contact information for our after-hours representative, who will assist you with 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-DC pre-authorization decisions are based on the following criteria:

  • MedStar Family Choice-DC Protocols
  • MedStar Family Choice-DC Pharmacy Policies and Procedures
  • InterQual
  • Medicare and Medicaid Guidelines
  • District of Columbia regulations and contract requirements
  • MedStar Family Choice-DC Managed Care Organization benefit coverage
  • MedStar Family Choice-DC Provider Manual
  • MedStar Family Choice-DC Enrollee Handbook
  • 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 available only when they are not available within the network, for continuity 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 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 member requests an extension or if MedStar Family Choice-DC determines an extension is in the best interest of the member. If the service requested is denied, the provider may contact our Utilization Management Department to discuss the decision with the appropriate Medical Director.

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

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, which are outside the guidelines set forth in the manual. Physicians may call MedStar Family Choice-DC at 855-798-4244, or fax requests to 202- 362-1393.

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.

Concurrent Review

MedStar Family Choice-DC utilizes the following criteria to make concurrent review decisions:

  • InterQual
  • 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.

Emergency Care

In accordance with the Emergency Medical Treatment & Labor Act (EMTALA), MedStar Family Choice-DC 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-DC 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-DC 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-DC 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-DC Decision Making

MedStar Family Choice-DC 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 our website. Providers may also call the MedStar Family Choice-DC Clinical Operations Department to request a written copy. Providers may request the UM criteria utilized for a specific case by calling the MedStar Family Choice-DC Clinical Operations Department at 855-798-4244.

For members with urgent authorization needs, physicians or a physician’s staff member should contact MedStar Family Choice-DC Clinical Operations Department at 855-798-4244. A decision regarding urgent authorizations will be made within 72 hours of receiving the request.

Substance Use Disorder

Admissions for alcohol or other substance use issues, even if admitted to a medical bed, are referred to Magellan Healthcare for authorization and claims payment. American Society of Addictive Medicine ASAM utilization management criteria are used per plan benefit.

To request inpatient authorizations for substance use admissions to medical beds, the hospital utilization reviewer may contact Magellan Healthcare directly by calling: 800-777-5327. Providers may also access Magellan Healthcare website https://www.magellanhealthcare.com/provider-portals/ for additional information.

Magellan Healthcare address for claims submission:

Magellan Health Services

PO Box 2271

Maryland Heights, MO 63043

 

This program is funded in part by the Government of the District of Columbia Department of Health Care Finance.
Information current as of: 09/21/20