§ 31-3875-06

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

(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. (Jan. 17, 2024, D.C. Law 25-100, § 106, 70 DCR 15238.)