Before submitting your prior authorization request:
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 District of Columbia (MFC-DC) Reviewer or Medical Director please contact us during our normal business hours (8 a.m. to 5:30 p.m.) at 855-798-4244 or 202-363-4348. Messages received outside of normal business hours will be addressed the following business day.
MFC-DC follows a basic prior-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 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 with requests for prior-authorization.
For Pharmacy requests only, use the Prior Authorization/Non-Formulary Medication Request Form, and fax to us at 202-243-6258.
Our experienced clinical staff reviews all requests. MFC-DC prior-authorization decisions are based on the following criteria:
MFC-DC Pharmacy Policies and Procedures
Medicare and Medicaid Guidelines
District of Columbia regulations and contract requirements
MFC-DC Managed Care Organization benefit coverage
District of Columbia DMS/DME Program Approved List of Items
Availability of services within the MFC-DC network
MFC-DC Continuity of Care Policy
UM Criteria Policy
MFC-DC reserves the right to direct services to participating providers and facilities. Services outside the network are allowed only when they are not available within the network, or for continuity of care reasons.
MFC-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.
MFC-DC allows up to fourteen (14) days to process non-urgent authorization requests. MFC-DC can take an additional 14 days to make a final decision if the provider or enrollee requests an extension or if MFC-DC determines an extension is in the best interest of the enrollee. If the service requested is denied, information on how to request an Appeal is included in the denial letter.
A limited number of services require authorization from MFC-DC before the patient receives care. The list is included in the MFC-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.
For Personal Care Assistant (PCA) Requests: Submit the electronic prescriber order form (ePOF) along with necessary medical records/clinical information for the date of service via Department of Health Care Finance (DHCF) portal.
For Pharmacy requests, MFC-DC must make a decision within 24-hours of receipt of the request. Please ensure that all pertinent clinical information is provided with the request to prevent any denial of service for lack of clinical information.
MFC-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 MFC-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. MFC-DC does not guarantee coverage of medications, which are outside the guidelines set forth in the manual. Physicians may call MFC-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 reviewMFC-DC utilizes the following criteria to make concurrent review decisions:
Medicare and Medicaid Guidelines
District of Columbia regulations or contract requirements
MFC-DC benefit coverage
Availability of services within the MFC-DC network
MFC-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 MFC-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).
In accordance with the Emergency Medical Treatment & Labor Act (EMTALA), MFC-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. MFC-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, MFC-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 reasonably 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.
MFC-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.
MFC-DC decision making
MFC-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 MFC-DC Clinical Operations Department to request a written copy. Providers may request the UM criteria utilized for a specific case by calling the MFC-DC Clinical Operations Department at 855-798-4244.
For enrollees with urgent authorization needs, physicians or a physician’s staff member should contact MFC-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
To request inpatient or outpatient authorizations for substance use conditions, please submit your requests along with necessary medical records/clinical information for the date of service to 202-243-6320 (fax). You can contact us during our normal business hours (8 a.m. to 5:30 p.m.) at 202-363-4348 or toll-free at 855-798-4244. Messages received outside of normal business hours will be addressed the following business day.
American Society of Addictive Medicine ASAM utilization management criteria are used per plan benefit.
Submit your request using the Prior Authorization (BH SUD) Request Form.
Information current as of: