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101 chapters · 1,108 sections in this title.
D.C. Code § 31-3875.01 Definitions
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(a) For purposes of this chapter, the term: (1) "Adverse determination" means a decision by a utilization review entity that the health care services furnished or proposed to be furnished to an enrollee is denied, reduced, or terminated as being not medically necessary or experim…
D.C. Code § 31-3875.02 Prior authorization requirements and restrictions
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(a)(1) A utilization review entity may only require prior authorization for a covered health care service based on a determination of medical necessity for different care or that the proposed care is experimental or investigational in nature. (2) A utilization review entity may n…
D.C. Code § 31-3875.03 Prior authorization in non-urgent, urgent, and emergency circumstances
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(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…
D.C. Code § 31-3875.04 Length of prior authorization
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(a) Except as otherwise provided in subsection (b) of this section, approval shall be valid for at least one year from the date the enrollee receives notice of the approval and shall remain valid regardless of any changes in dosage for a prescription drug prescribed by the health…
