§ 31-3875.03 — Prior authorization in non-urgent, urgent, and emergency circumstances.

District of Columbia § 31-3875.03

• Jurisdiction: District of Columbia
• Title 31: Insurance and Securities.
• Ch. 38F: Prior Authorization by a Utilization Review Entity.

Text

(a) If a utilization review entity requires prior authorization of a health care service, the utilization review entity shall, after receiving all required information to make its decision, make an approval or adverse determination and notify the enrollee, representative, and the enrollee's health care provider of its decision within:

(1) For an urgent health care service, 24 hours;

(2) Not Funded.

(3) For all other health care services, 3 business days of receiving the request via electronic portal or 5 business days of receiving the request via mail, telephone, or facsimile.

(b) A health care service described under subsection (a) of this section shall be deemed approved if the utilization review entity does not provide notice within the time frames provided by that subsection.

(c) The notice required under subsection (a) of this section shall include:

(1) The qualifications of the individual making the determination, including:

(A) States in which the individual is licensed;

(B) Status of their medical licenses; and

(C) Their medical specialty; and

(2) For an adverse determination, an explanation of:

(A) The utilization review entity's reasons for making an adverse determination based on its prior authorization requirements;

(B) The enrollee's right to appeal;

(C) The process to file an appeal; and

(D) All information necessary to support a successful appeal of the adverse determination.

(1) If the utilization review entity determines that required information is missing, the utilization review entity shall promptly notify the enrollee, representative, and the enrollee's health care provider of its need for additional information.

(2) Prior to issuing an adverse determination, the utilization review entity shall notify the enrollee's health care provider that the medical necessity of the health care service is being questioned and give the responsible physician an opportunity to provide additional information or clarification on the medical necessity of the health care service.

(1) A utilization review entity shall provide an enrollee, representative, and the enrollee's health care provider a minimum of 24 hours (excluding weekends and legal public holidays) following an emergency hospital admission or the provision of an emergency health care service to notify the utilization review entity of the admission or provision of the emergency health care service.

(2) If a health care provider certifies in writing to a utilization review entity within 72 hours of an enrollee's receipt of an emergency health care service that the enrollee's condition required the provision of such service, the service shall be presumed to have been medically necessary and may be rebutted only if the utilization review entity establishes through clear and convincing evidence that the emergency health care service was not medically necessary.

(3) A utilization review entity may not consider whether the emergency health care service was provided by a nonparticipating provider when determining the medical necessity or appropriateness of the service and may not impose greater restrictions on the coverage of emergency health care services provided by nonparticipating providers than those that apply to the same services provided by participating providers.

(f) For purposes of this section, the term "required information" includes the results of any face-to-face clinical evaluation or second opinion that may be required under the utilization review entity's prior authorization requirements.