District of Columbia DC

DC Medicaid FFS prior authorization is split across three contractors, not one DHCF page. (1) MEDICAL items/services PA is administered by Comagine Health (UM/PA contractor) via the Comagine Health Provider Portal (CHPP) and the legacy dc-medicaid.com webportal; the authoritative list is "Medical Items and Services that Require Prior Authorization" (dc-um-pa-services-list.pdf). DC uses InterQual for medical-necessity criteria (public transparency view at prod.ds.interqual.com). The universal medical PA submission form is the 719A. (2) PHARMACY (FFS) PA is administered by Prime Therapeutics via dc-pbm.com (formerly Magellan; transition 2024-10-01); criteria live as the PDL (dc.fhsc.com), per-drug clinical criteria + per-drug PA fax forms, and the District FFS Pharmacy Provider Manual. (3) The Gainwell MMIS provider portal (medicaid.dc.gov, live 2026-01-20, replaced Conduent legacy MMIS 2026-03-02) hosts service-specific billing manuals (PA rules embedded per service), forms, and transmittals; the General Billing Manual is login-gated but Physicians/Outpatient/LTC manuals are public direct-PDF. DHCF itself (dhcf.dc.gov) is the policy authority but does NOT host a single PA-criteria index; the previously-pinned pa_index https://dhcf.dc.gov/page/prior-authorization is now 404 (DEAD). Managed-care PA (3 MCOs: AmeriHealth Caritas DC, CareFirst CHPDC, MedStar Family Choice DC; homepage also references Wellpoint DC) is delegated to each MCO. BH (MHRS/ASARS) is carved out to DBH FFS. AUTHORITY = DHCF (policy) but OPERATIONAL criteria custody is held by the contractors. Gainwell portal download URL pattern: https://medicaid.dc.gov/SPDocumentLibrary/DocumentLibrary/<folder>/<filename>.

Last award: 2022-10-18. Next due: approx 2027 RFP, 2028 award (5-year cycle). Contracts extended through: None.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How DC requires PA District of Columbia (DC) Medicaid's prior authorization (PA) process is intricate and involves multiple contractors and specific criteria for various services. The primary contractor for medical items/services PA is Comagine Health, which utilizes the Comagine Health Provider Portal (CHPP) and the legacy dc-medicaid.com web portal. For pharmacy services under the fee-for-service (FFS) population, Prime Healthcare serves as the pharmacy benefit manager (PBM), while Gainwell Technologies manages the Medicaid Management Information System (MMIS) portal. Specific PA requirements vary by service category: - **Dental Services**: Detailed criteria are outlined in documents like D0160 for extensive oral evaluations and D0364 for Cone Beam CT scans, effective January 2025. - **MAT Drug Products**: Prior authorization is required with medical necessity documentation but no step therapy specified, as per the District_FFS_Provider_Manual.pdf dated August 9, 2023. - **Home Health Services**: The DC-UM-CHPP-719A-PA-Form.pdf requires face-to-face encounter documentation by an allowed prescriber, effective June 2018. - **Preferred Drug Program**: Providers must document the diagnosis and reason for non-preferred drug use as per the DC_Preferred_Drug_Program_PA_Form.pdf, last revised November 13, 2015. - **Non-PDL PA Request**: This form requires a diagnosis justification and no preferred drug substitution, with prescriber signature and date, though the effective/revised date is unspecified. ## 2. How DC publishes and reports PA DC Medicaid publishes its PA criteria and forms through various documents and portals: - **Provider Manuals**: These manuals provide comprehensive guidelines for providers on PA requirements. For example, the District_FFS_Provider_Manual.pdf revised December 10, 2025, covers general PA rules. - **Specific Service Guidelines**: Detailed service-specific guidelines are available in documents like D0160 and D0364 for dental services, effective January 2025. - **Online Portals**: The Comagine Health Provider Portal (CHPP) and the legacy dc-medicaid.com web portal are used by providers to submit PA requests and track status. Gainwell Technologies’ MMIS portal also plays a role in managing these processes. Reporting on PA activities is likely conducted through internal systems managed by contractors like Comagine Health, Prime Healthcare, and Gainwell Technologies. However, specific reporting mechanisms or public dashboards are not detailed in the provided documents. ## 3. DC's CMS-0057-F and PA-reform compliance posture DC Medicaid’s compliance with CMS-0057-F, which outlines requirements for prior authorization reform, is influenced by several factors: - **Gold Card Law (D.C. Law 25-100)**: This law aims to streamline the PA process and reduce administrative burden on providers. It was enacted in 2023 but specific implementation details are not provided in the given documents. - **Behavioral Health Transformation Demonstration**: DC’s 1115 waiver, now proposed for renewal as 'Whole-Person Care Transformation', includes carve-outs for behavioral health services managed by the District of Columbia Department of Behavioral Health (DBH) FFS. This suggests a focus on specialized PA processes for BH services. - **InterQual Criteria**: The use of InterQual criteria indicates adherence to standardized medical necessity guidelines, which is a key component of CMS-0057-F compliance. While DC has taken steps towards reform through the Gold Card Law and specific carve-outs, detailed implementation timelines and full compliance status with CMS-0057-F are not explicitly stated in the provided findings. ## 4. How DC runs its own program DC Medicaid operates a complex system involving multiple contractors and specialized programs: - **Contractors**: The primary contractors include Comagine Health for medical PA, Prime Healthcare as the PBM for pharmacy services, and Gainwell Technologies for MMIS management. - **Carve-Outs**: Specific carve-outs are in place for pharmacy (carved into MCO with FFS PBM), long-term supports and services (LTSS) managed by state FFS, behavioral health services managed by DBH FFS, and foster care programs. - **WISeR**: Not applicable to DC. WISeR = CMS "Wasteful and Inappropriate Service Reduction," a Medicare prior-authorization model running in only six states (AZ, NJ, OH, OK, TX, WA). DC is not a participant, and the placeholder finding should not be read as a signal of innovation or testing. The procurement cycle for Managed Care Organizations (MCOs) follows a 5-year schedule with the last award on October 18, 2022, and the next RFP expected around 2027. This cyclical approach ensures regular review and potential updates to the MCO contracts. ## 5. Patterns, what's notable, and what's missing/uncertain **Patterns:** - **Specialized PA Criteria**: DC Medicaid has detailed criteria for specific services like dental procedures (D0160, D0364) and MAT drug products. - **Use of InterQual**: The use of standardized medical necessity guidelines via InterQual suggests a structured approach to PA. - **Multiple Contractors**: The involvement of multiple contractors (Comagine Health, Prime Healthcare, Gainwell Technologies) indicates a segmented but integrated system. **Notable:** - **Gold Card Law**: The recent Gold Card Law aims to reform the PA process, potentially reducing administrative burdens and improving access to care. - **Behavioral Health Carve-Out**: Specialized management of behavioral health services by DBH FFS highlights DC’s focus on mental health integration within Medicaid. **Missing/Uncertain:** - **WISeR**: Not applicable to DC (WISeR is a Medicare PA model in AZ, NJ, OH, OK, TX, WA only); the placeholder finding is not a signal. - **Full Compliance Details**: While there are indications of reform efforts (Gold Card Law), specific details on full compliance with CMS-0057-F are not provided. - **Reporting Mechanisms**: There is no information on how DC Medicaid publicly reports PA activities or performance metrics, which could be valuable for transparency and accountability.