What is prior authorization?
Prior authorization (PA) means the carrier must approve certain care before it happens. A PA denial is different from a claim denial after care was provided.
Overview for any state: Prior authorizations. This page is District of Columbia–only.
Confirm plan type: District of Columbia: Start Here.
D.C. PA deadlines
The Prior Authorization Reform Amendment Act of 2023 (D.C. Law 25-100), codified at D.C. Code Title 31, Chapter 38F (§§ 31-3875.01–31-3875.10), sets timelines for utilization review entities on D.C.-regulated plans.
Non-urgent services
- Electronic submission: notice within 3 business days of a complete request
- Mail, telephone, or fax: within 5 business days
Urgent services
- Urgent PA: within 24 hours of receiving needed information
- Long-term services and supports (Medicaid): often up to 30 days under D.C. rules
If the plan misses deadlines
Failure to meet required notice timeframes can result in the request being deemed approved (§ 31-3875.08). Document when the request was submitted and every carrier response.
Other protections
- PA generally cannot be required solely on cost (with limited Medicaid exceptions)
- No PA for emergency care or pre-hospital transport under Chapter 38F
- Substance-use disorder medications: separate protections under D.C. mental health parity laws (Title 7, Ch. 12)
- Electronic PA via NCPDP SCRIPT standard required for utilization review entities
Where to look up PA rules
Match tools to the exact plan on the ID card. Major DC Health Link carriers:
- CareFirst BlueCross BlueShield: carefirst.com
- Kaiser Permanente Mid-Atlantic: kaiserpermanente.org — D.C.
- UnitedHealthcare: uhc.com
D.C. Medicaid & Alliance
Medicaid and Alliance PA follow DHCF and MCO rules—not commercial Chapter 38F alone. Service denials: MCO grievance, then fair hearing—see DHCF — grievances/appeals.
If PA is denied
- Get the adverse determination in writing with clinical reasons and appeal instructions.
- Ask the treating clinician for records and a medical-necessity letter.
- Request an internal appeal within 180 days— D.C. internal appeals.
- If care cannot wait, request expedited review (24-hour decision window for urgent appeals).
Building a strong appeal packet has a checklist.
Urgent care
Use the 24-hour PA rule for urgent requests. For urgent denials, internal appeals must be concluded within 24 hours of notification (§ 44-301.06(f)). You may be able to go straight to external review—see D.C. external review.