Section 31-3875.06 - Review personnel qualifications(a)(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.(b)(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.Added by D.C. Law 25-100,§ I-106, 70 DCR 015238, eff. 1/17/2024.