# D.C. Code § 31-3875.06: Review personnel qualifications

> District of Columbia · Statutes · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.06

## Section

- **Citation:** D.C. Code § 31-3875.06
- **Heading:** Review personnel qualifications
- **Jurisdiction:** District of Columbia
- **Kind:** Statutes
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** DC Code / Title 31 / Chapter 38F / § 31-3875.06

## Text

(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 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.

## Nearby sections

- [D.C. Code § 31-3875.01 § 31-3875.01. Definitions.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.01.md)
- [D.C. Code § 31-3875.02 § 31-3875.02. Prior authorization requirements and restrictions.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.02.md)
- [D.C. Code § 31-3875.03 § 31-3875.03. Prior authorization in non-urgent, urgent, and emergency circumstances.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.03.md)
- [D.C. Code § 31-3875.04 § 31-3875.04. Length of prior authorization.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.04.md)
- [D.C. Code § 31-3875.05 § 31-3875.05. Appeals.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.05.md)
- [D.C. Code § 31-3875.06 § 31-3875.06. Review personnel qualifications.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.06.md)
- [D.C. Code § 31-3875.07 § 31-3875.07. Continuity of care for enrollees.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.07.md)
- [D.C. Code § 31-3875.08 § 31-3875.08. Failure to comply and penalties.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.08.md)
- [D.C. Code § 31-3875.09 § 31-3875.09. Data transparency.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.09.md)
- [D.C. Code § 31-3875.10 § 31-3875.10. Rulemaking.](https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.10.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_DC_T31_C38F_S31-3875.06. Check the current official text before relying on it. Not legal advice.