District of Columbia § 31-3875.06 Review personnel qualifications.

District of Columbia Statutes

§ 31-3875.06 — Review personnel qualifications.

District of Columbia § 31-3875.06

Title 31Insurance and Securities.

Ch. 38FPrior Authorization by a Utilization Review Entity.

This text of District of Columbia § 31-3875.06 (Review personnel qualifications.) is published on Counsel Stack Legal Research, covering District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

D.C. Code § 31-3875.06 (2026).

Text

(1)A utilization review entity shall ensure that an adverse determination is made by a physician who:

(A)Possesses a current and valid non-restricted license to practice medicine in the District, Maryland, or Virginia; and

(B)Is of the same or similar specialty as a physician who typically manages the medical condition or disease or provides the health care service involved in the request; provided, that a physician making an adverse determination for pediatric care shall have a pediatric specialty.

(2)The reviewing physician shall:

(A)Be under the clinical direction of one of the utilization review entity's medical directors licensed in the District who is responsible for providing health care services to enrollees in the District; and

(B)Not receive any fin

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(1) A utilization review entity shall ensure that an adverse determination is made by a physician who:

(A) Possesses a current and valid non-restricted license to practice medicine in the District, Maryland, or Virginia; and

(B) Is of the same or similar specialty as a physician who typically manages the medical condition or disease or provides the health care service involved in the request; provided, that a physician making an adverse determination for pediatric care shall have a pediatric specialty.

(2) The reviewing physician shall:

(A) Be under the clinical direction of one of the utilization review entity's medical directors licensed in the District who is responsible for providing health care services to enrollees in the District; and

(B) Not receive any financial incentive based on the number of adverse determinations made; except, that the utilization review entity may establish medically appropriate performance standards.

(1) A utilization entity shall ensure that all appeals are reviewed by a physician who:

(A) Possesses a current and valid non-restricted license to practice medicine in the District, Maryland, or Virginia;

(B) Is of the same or similar specialty as a physician who typically manages the medical condition or disease or provides the health care service involved in the request; provided, that the physician reviewing an appeal for pediatric care shall have a pediatric specialty and practiced that specialty for at least 5 years; and

(C) Is knowledgeable of, and have experience providing, the health care service on appeal.

(2) A physician reviewing an appeal shall not:

(A) Receive any financial incentive based on the number of adverse determinations made or upheld on appeal; provided, that the utilization review entity may establish medically appropriate performance standards;

(B) Have been directly involved in making the adverse determination; and

(C) Be subordinate of the physician who made the adverse determination.