D.C. Mun. Regs. r. 7-127
Any medical care or service furnished or scheduled to be furnished under the Act shall be subject to utilization review, regardless of whether prior authorization was required for the medical care or service. The utilization review may be performed before, during, or after the medical care or service is provided. Medical care under this section includes medical appliances and supplies.
A utilization review organization or individual used pursuant to the Act shall be certified by the Utilization Review Accreditation Commission.
The claimant, the Program, or the Chief Risk Officer's hearing representative may initiate utilization review if it appears that the necessity, character, or sufficiency of medical care or services furnished or scheduled to be furnished is improper or needs to be clarified.
Utilization review shall be initiated only for medical care or services provided, or scheduled to be provided, for treatment of a condition that the Program has accepted as being compensable under the Act.
The utilization review report shall specify the medical records considered and shall set forth rational medical evidence and standards to support each finding. The report shall be authenticated or attested to by the utilization review individual or by an officer of the utilization review organization. The report shall be provided to the claimant, qualified health professional, and the Program.
A utilization review report which conforms to the provisions of this section shall be admissible in all proceedings with respect to any claim to determine whether a medical care or service was, is, or may be necessary and appropriate to treat a condition that has been accepted by the Program as being compensable under the Act.
A decision issued by the utilization review organization or individual under this section shall inform the claimant and qualified health professional of their right to reconsideration before the utilization review organization.
If the qualified health professional or claimant disagrees with the opinion of the utilization review organization or individual, the qualified health professional or claimant may submit a written request to the utilization review organization or individual for reconsideration of the opinion.
The request for reconsideration shall:
A decision issued on reconsideration pursuant to Section 2323 (a-2)(3) of the Act (D.C. Official Code § 1-623.23 (a-2)(3)) is final and not subject to further review on the issue of necessity, character, or sufficiency of the medical care or service provided, or scheduled to be provided.
Where utilization review has not been initiated, a dispute regarding the issue of necessity, character, or sufficiency of the medical care or service provided, or scheduled to be provided may, pursuant to Section 2323 (a-2)(4) of the Act (D.C. Official Code § 1-623.23 (a-2)(4)), be resolved upon an application for a hearing before the Chief Risk Officer pursuant to § 157 of this chapter within thirty (30) calendar days after the date of the Program's decision denying authorization for medical care or services.
A request for a hearing under § 127.12 of this chapter may be made by the Program, qualified health professional, or claimant.
As provided in Section 2323 (a-2)(4) of the Act (D.C. Official Code § 1-623.23 (a-2)(4)), the Superior Court of the District of Columbia may review the Chief Risk Officer's decision. The decision may be affirmed, modified, revised, or remanded at the discretion of the court. The decision shall be affirmed if supported by substantial competent evidence of the record, pursuant to the District of Columbia Superior Court Rules of Civil Procedure Agency Review.
The District of Columbia government shall pay the cost of a utilization review if the claimant seeks the review and is the prevailing party. The claimant shall pay the cost of a utilization review if the claimant seeks the utilization review and the Program is the prevailing party. Utilization review services, if paid by the Program, may be recovered under Section 2329 of the Act (D.C. Official Code § 1-623.29 ).
The Program may deny a request by a qualified health professional for authorization for medical care or services furnished, or scheduled to be furnished, where insufficient information has been provided to initiate utilization review.
If the Program makes payment for medical care or services that are later denied pursuant to utilization review, the Program shall recoup such payment as an overpayment in accordance with Section 2329 of the Act (D.C. Official Code § 1-623.29 ).
The Program may enter into a working agreement with a utilization review organization or individual to carry out the utilization reviews authorized under this section. Each such agreement shall set forth terms and conditions to ensure appropriate review, including fee, and payment guidelines.
D.C. Mun. Regs. r. 7-127