ENROLLED ORIGINAL
AN ACT
_________________
IN THE COUNCIL OF THE DISTRICT OF COLUMBIA
______________________________
To prescribe the manner in which a utilization review entity shall make publicly available
information on prior authorization requirements and restrictions, to set notice
requirements for prior authorization determinations, to prescribe the minimum length that
a prior authorization approval shall be considered valid, to set the qualifications for
personnel authorized to make adverse determinations and appeals, to permit enrollees to
appeal an adverse determination and to set deadlines for submissions of appeals, to
prescribe a utilization review entity’s obligations to review requests for prior
authorization for non-urgent, urgent, and emergency health care services, to permit
utilization review entities to require prior authorization only when based on a
determination of medical necessity for different care and to prohibit a utilization review
entity from requiring prior authorization for a treatment solely based on cost, to prohibit a
utilization review entity from revoking, limiting, conditioning, or restricting approval if
care was provided within 45 days of approval, to require that a utilization review entity
honor an approval granted by a previous utilization review entity for at least the initial 60
days of coverage, to clarify that health care services are deemed authorized if a utilization
review entity fails to comply with title I of this act, and to require a utilization review
entity make certain statistics available to the public; to amend the Uniform Health
Insurance Claims Forms Act of 1995 to require all utilization review entities accept and
respond to prior authorization requests using the NCPDP SCRIPT Standard ePA
transaction by January 1, 2024; and to amend the Health Insurance Portability and
Accountability Federal Law Conformity and No-Fault Motor Vehicle Insurance Act of
1998 to require that employers provide notice to employees of treatments, including
particular services or medications, not included in the negotiated health benefit plan but
that are included in the standard health benefit plan or formulary offered by the health
insurer.
BE IT ENACTED BY THE COUNCIL OF THE DISTRICT OF COLUMBIA, That this
act may be cited as the “Prior Authorization Reform Amendment Act of 2023”.
1
 ENROLLED ORIGINAL
TITLE I. PRIOR AUTHORIZATION.
Sec. 101. Definitions.
For purposes of this title, 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 experimental or investigational.
(2) “Approval” means a determination by a utilization review entity that a covered
health care service has been reviewed and, based on the information provided, satisfies the
utilization review entity’s requirements for medical necessity and medical appropriateness.
(3) “Emergency health care service” means a health care service that is provided
in an emergency facility after the sudden onset of a medical condition that manifests itself by
symptoms of sufficient severity, including severe pain, that the absence of immediate medical
attention could reasonably be expected by a prudent layperson, who possesses an average
knowledge of health and medicine, to place the patient’s health in serious jeopardy or to cause
serious impairment to bodily function or serious dysfunction of any bodily organ or part.
(4) “Enrollee” means an individual eligible to receive health care benefits by a
health insurer pursuant to a health plan or other health insurance coverage.
(5) “Long-term services and supports” means institutional and home and
community-based services provided under the District’s Medicaid State Plan or any
corresponding waiver thereof, including long-term nursing facility care, intermediate care facility
services, State Plan home health and personal care aide services, services covered under the
Program for All-Inclusive Care for the Elderly, and home and community-based services
authorized under section 1915(c) and (i) of the Social Security Act, approved August 13, 1981
(95 Stat. 809; 42 U.S.C. 1396n(c) and (i)), and section 1115 of the Social Security Act, approved
July 25, 1962 (76 Stat. 192; 42 U.S.C. § 1315).
(6) “Medication assisted treatment” means the use of medications to provide a
comprehensive approach to the treatment of substance use disorders.
(7) “Prior authorization” means the process by which a utilization review entity
determines the medical necessity or medical appropriateness of covered health care services prior
to the rendering of such services, including any notification that an enrollee or health care
provider is required to provide to the health insurer or utilization review entity prior to the
provision of a health care service.
(8) “Representative” means the enrollee’s legally authorized representative.
(9) “Urgent health care service” means:
(A) A health care service that, in the opinion of a physician with
knowledge of the enrollee’s medical condition, if not receiving an expedited approval:
2
 ENROLLED ORIGINAL
(i) Could seriously jeopardize the life or health of the enrollee or
the ability of the enrollee to regain maximum function; or
(ii) Could subject the enrollee to severe pain that cannot be
adequately managed without the care or treatment that is the subject of the prior authorization
review; or
(B) Medication assisted treatment.
(10) “Utilization review entity” means an individual or entity that performs prior
authorization review for:
(A) A health insurer as that term is defined in section 5040 of the Healthy
DC Act of 2008, effective August 16, 2008 (D.C. Law 17-219; D.C. Official Code § 4-631);
(B) A preferred provider organization or health maintenance organization
as those terms are described in section 2105(2) and (3) of the District of Columbia
Comprehensive Merit Personnel Act of 1978, effective October 1, 1987 (D.C. Law 8-190; D.C.
Official Code § 1-621.05(2) and (3));
(C) A health benefits plan provided through Medicaid;
(D) A health benefits plan provided through DC HealthCare Alliance; or
(E) Any other individual or entity that provides, offers to provide, or
administers hospital, outpatient, medical, prescription drug, or other health benefits to a person
treated by a health care provider in the District under a policy, plan, or contract that is regulated
by the District.
Sec. 102. Prior authorization requirements and restrictions.
(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 not require prior authorization:
(A) Based solely on the cost of a covered health care service; provided,
that:
(i) A health benefits plan provided through Medicaid may require
prior authorization based on a preferred drug list; and
(ii) A health benefits plan provided through DC HealthCare
Alliance may require prior authorization based on a preferred drug list;
(B) For the provision of medication assisted treatment; or
(C) For pre-hospital transportation or for the provision of emergency
health care services, including emergency health care services to screen and stabilize an enrollee.
(b) A utilization review entity shall:
3
 ENROLLED ORIGINAL
(1) Post its current prior authorization requirements and restrictions, including
formulary (“prior authorization requirements”), on its website, in a manner accessible to the
general public without the need to create an account;
(2) Email or provide a hard copy of the prior authorization requirements to an
enrollee, representative, or health care provider upon request by telephone or in writing; and
(3) Provide information on its prior authorization requirements, upon request, to
an enrollee, representative, or health care provider over the telephone.
(c) Prior authorization requirements shall:
(1) Be described in detail and easily understandable language;
(2) Include any written clinical criteria;
(3) Include a comprehensive listing of all drugs that require prior authorization;
and
(4) Include the process for submitting, and standards for considering, including
evidence-based guidelines, where possible, requests for:
(A) Prior authorization approval;
(B) Reauthorization of a prior grant of approval; and
(C) An appeal of an adverse determination.
(d) If a utilization review entity intends to amend or replace its prior authorization
requirements, any changes to the requirements shall not be effective until the utilization review
entity’s website has been updated to reflect the new requirements.
Sec. 103. Prior authorization in non-urgent, urgent, and emergency circumstances.
(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) For long-term services and supports, 30 days; provided, that the enrollee has
been determined to be otherwise eligible for such benefits under Medicaid; and
(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;
4
 ENROLLED ORIGINAL
(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.
(d)(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.
(e)(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.
5
 ENROLLED ORIGINAL
Sec. 104. Length of prior authorization.
(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 care
provider; provided, that the utilization review entity may rescind the approval for dosages
exceeding limitations set by federal or District laws or regulations.
(b)(1) Approval for a course of treatment, as that term is defined at 2 CFR
422.112(b)(8)(ii)(A), or for a health care service to treat a chronic condition, shall remain valid
for as long as medically reasonable and necessary to avoid disruptions in care, in accordance
with applicable coverage criteria, the enrollee’s medical history, and the treating provider’s
recommendation.
(2) The Department of Health Care Finance may require annual reauthorization
for long-term services and supports.
(c) A utilization review entity may not revoke, limit, condition, or restrict approval if care
is provided within 45 business days from the date the enrollee receives notice of the approval;
provided, that approval may be revoked or otherwise restricted in cases of fraud.
Sec. 105. Appeals.
(a) A utilization review entity shall provide an enrollee with at least 15 calendar days
from the date the enrollee receives notice of an adverse determination to appeal the decision via
the utilization review entity’s website, facsimile, or mail; provided, that an appeal submitted by
mail shall be considered timely if postmarked within 15 calendar days of the enrollee receiving
notice.
(b) In reviewing an appeal, the utilization review entity shall consider all known clinical
aspects of the health care service under review, including a review of all pertinent medical
records, other relevant records, and any medical literature provided by the enrollee,
representative, or the enrollee’s health care provider.
(c) The enrollee, representative, and the enrollee’s health care provider shall be notified
within 24 hours of the utilization review entity making a decision on the appeal, which shall
include the following information:
(1) The qualifications of the physician reviewing the appeal including:
(A) States in which the physician is licensed;
(B) Status of their medical licenses;
(C) Their medical specialty; and
(D) Years of practice in that specialty; and
(2) The grounds for the physician’s decision under the utilization review entity’s
prior authorization requirements.
6
 ENROLLED ORIGINAL
Sec. 106. 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 subo