Prior Authorization

Utilization Management (UM) within the Healthy DC Plan ensures that members receive medically necessary, appropriate, timely and cost-effective care.

  • Pharmacy Authorizations will be managed by CVS
  • Non-pharmacy Authorizations will be managed by the UM Team
  • Urgent requests are reviewed within 24 hours
  • Non-urgent requests are reviewed within 5 days

Provider submits request for authorization for services for inpatient and/or outpatient services, as per the Prior Authorization grid.

UM staff will complete initial review according to benefit guidelines and criteria.

If the requested service does not require prior authorization, the UM Team will notify the Member's Provider.

Any request that does not meet criteria or needs further review will be sent to a Medical Director for determination.

 

Inpatient Concurrent Review

Initial Request for Inpatient Authorization: All initial Requests for Authorization of inpatient days must be accompanied by clinical  information. MFC-DC will make an authorization decision within 72 hours of receipt of  all clinical information.

Notification of Admissions: MFC-DC will document the information on the Daily  Communication Log sent to the hospital; until clinical information is received, or notification is  received that the enrollee is discharged.

Continued Stay Review: For ongoing inpatient reviews/authorization, MFC-DC will document the next scheduled  review due date on the Daily Communication Log. We will make a determination within three (3) calendar days of receipt of clinical information. If clinical information is not received on the scheduled review due date, the day(s) may be subject to denial for lack of information.

  • Submitting medical records or clinical information for the date of service  will assist greatly in the decision process.
  • If an Inpatient day is denied, the hospital can request an expedited or  urgent Appeal either verbally or in writing; only if the enrollee is still  inpatient.
  • If an Inpatient day is pended or denied, the facility or attending physician can request a Peer-to-Peer review with an MFC-DC’s Medical Director, while the enrollee remains inpatient or up to three (3) business days after discharge.

Information current as of: