Preauthorization and Utilization Management

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 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 202-243-6258 (fax). 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.

For PCA Requests: Submit the electronic prescriber order form (ePOF) along with necessary medical records/clinical information for the date of service via Department Healthcare Finance (DHCF) portal.

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-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, 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. Submit your requests to 202-243-6258 (fax).  

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

• 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.

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