{"data":{"id":"us-dc/d.c.-code-31-3875.05","jurisdiction":"us-dc","citation":"D.C. Code § 31-3875.05","heading":"Appeals.","body":"(a)\nA 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.\n\n(b)\nIn 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.\n\n(c)\nThe 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:\n(1)\nThe qualifications of the physician reviewing the appeal including:\n(A)\nStates in which the physician is licensed;\n(B)\nStatus of their medical licenses;\n(C)\nTheir medical specialty; and\n(D)\nYears of practice in that specialty; and\n(2)\nThe grounds for the physician's decision under the utilization review entity's prior authorization requirements.","path":["Title 31. Insurance and Securities.","Chapter 38F. Prior Authorization by a Utilization Review Entity."],"source_url":"https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.05","current_through":"2026-08-20 (D.C. Law 26-175)","vintage":"","retrieved_at":"2026-08-29T05:44:07Z","sha256":"c26d7edf8c77d4dc0c8f17fa0868548fea5cd857712b04bf24b5735422071fcb","source_id":"us-dc","stale":false,"prev":"us-dc/d.c.-code-31-3875.04","next":"us-dc/d.c.-code-31-3875.06"},"notice":"GroundRules: Original legal text. Not legal advice."}