{"data":{"id":"us-dc/d.c.-code-31-3875.06","jurisdiction":"us-dc","citation":"D.C. Code § 31-3875.06","heading":"Review personnel qualifications.","body":"(a)\n(1)\nA utilization review entity shall ensure that an adverse determination is made by a physician who:\n(A)\nPossesses a current and valid non-restricted license to practice medicine in the District, Maryland, or Virginia; and\n(B)\nIs 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.\n(2)\nThe reviewing physician shall:\n(A)\nBe 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\n(B)\nNot receive any financial incentive based on the number of adverse determinations made; except, that the utilization review entity may establish medically appropriate performance standards.\n\n(b)\n(1)\nA utilization entity shall ensure that all appeals are reviewed by a physician who:\n(A)\nPossesses a current and valid non-restricted license to practice medicine in the District, Maryland, or Virginia;\n(B)\nIs 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\n(C)\nIs knowledgeable of, and have experience providing, the health care service on appeal.\n(2)\nA physician reviewing an appeal shall not:\n(A)\nReceive 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;\n(B)\nHave been directly involved in making the adverse determination; and\n(C)\nBe subordinate of the physician who made the adverse determination.","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/31-3875.06","current_through":"2026-08-20 (D.C. Law 26-175)","vintage":"","retrieved_at":"2026-08-29T05:44:07Z","sha256":"cffa144c7ced11bd66a730beb60313c19a660eca45c39d5174bac35499d1d922","source_id":"us-dc","stale":false,"prev":"us-dc/d.c.-code-31-3875.05","next":"us-dc/d.c.-code-31-3875.07"},"notice":"GroundRules: Original legal text. Not legal advice."}