MedStar Family Choice DC is the second of the two DC Healthy Families plans DHCF lists. Its October 2025 provider manual does not mention ABA, but its Quick Authorization Guide (effective August 15, 2026) does: ABA services sit on the short list of in-network outpatient services that need prior authorization.
The Quick Authorization Guide says in-network outpatient services need no authorization "unless included below under the ‘Exceptions Requiring Prior Authorization’ section," and the first exception listed is "ABA Services: Prior Authorization Required." All out-of-network services need authorization. The manual says requests go by phone or fax with clinical information, codes must match what is requested and billed, and the UM line is 855-798-4244, with behavioral health requests faxed to 202-243-6320. Its listed criteria include InterQual, Medicare and Medicaid guidelines and DHCF contract requirements; it names no ABA-specific criteria.[1][2][3][8]
Standard pre-service decisions come "no later than 14 calendar days of receipt," and "The final decision cannot take longer than 14 days, regardless whether all clinical information has been received." Federal rules have since capped standard decisions at 7 calendar days for rating periods starting on or after January 1, 2026. A provider can discuss a denial with the medical director through the UM line; members appeal within 60 calendar days of the notice.[1][2][3][8]
Claims are due "within 365 days from the date of service," on a CMS-1500 or UB-04, with the mandatory data elements of DC fee-for-service; MedStar applies NCCI edits. Electronic claims use payer ID RP062; paper claims go to MedStar Family Choice DC, DC Claims Processing Center, P.O. Box 211702, Eagan, MN 55121. Clean claims are paid within 30 days under the District’s Prompt Payment Act, with interest of 1.5% (days 31–60), 2% (61–120) and 2.5% after. When a child has other insurance, bill it first and send MedStar the claim with the primary remittance, including the denial reason, "within 180 calendar days of the primary remittance date."[2]
The questions that decide whether a family can start with MedStar Family Choice District of Columbia, and what they have to bring. Each maps onto something intake should ask on the first call.
The plan publishes nothing different, so the state list applies: physician, PA, psychologist, psychology associate, LPC, LICSW or APRN (SPA 23-0009).[2][6]
The plan names no instrument; the state requires "a validated assessment tool or instrument" (SPA 23-0009).[2][6]
The plan publishes nothing ABA-specific; the state requires ASD services to be recommended by a physician or other licensed practitioner (SPA 23-0009).[2][6]
MedStar says it "will cover and reimburse healthcare services delivered through Telemedicine in accordance with District regulations." DHCF’s guidance (which covers managed care) applies: modifier GT (video) or 93 (audio-only), POS 10 home, 03 school or 02 other. No ABA telehealth code list was found.[2][7]
Other insurance "must be billed as the primary payor"; MedStar pays as secondary within its allowable amount, and the claim with the primary remittance must arrive within 180 calendar days of the primary remittance date. Members are not billed copays or deductibles.[2][9]
The manual: standard decisions "no later than 14 calendar days of receipt," and the final decision "cannot take longer than 14 days." Federal law caps standard decisions at 7 calendar days for rating periods starting on or after January 1, 2026.[2][8]
Ask the plan: MedStar Family Choice DC UM, 855-798-4244.
Coverage decides whether MedStar Family Choice District of Columbia pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
The plan publishes no ABA supervision rule of its own. The state rule applies: an RBT works under a BCBA, BCBA-D or BCaBA, and a BCaBA under a BCBA or BCBA-D (SPA 23-0009), with no numeric ratio.[2][6]
Not addressed in the manual or the Quick Authorization Guide; MedStar applies CMS NCCI edits to claims.[2]
Ask the plan: MedStar Family Choice DC Claims, 800-261-3371, or Provider Relations: ask whether 97153 and 97155 may be billed for the same time.
The plan publishes no ABA unit limit; units are set per authorization.[2][1]
Ask the plan: MedStar Family Choice DC UM, 855-798-4244.
The manual publishes no ABA session-note signature rule; it requires all billed codes to be supported by the medical record.[2]
Ask the plan: MedStar Family Choice DC Provider Relations, 800-261-3371.
The plan publishes no ABA setting rule.[2]
Ask the plan: MedStar Family Choice DC UM: ask which POS codes it pays for ABA.
The manual publishes no ABA rendering-provider rule (it requires NP and PA claims under the NP’s or PA’s own name).[2]
Ask the plan: MedStar Family Choice DC Provider Relations (MFCDC-ProviderRelations@MedStar.net): ask whether RBTs are billed under the supervising BCBA’s NPI.
Yes. Its Quick Authorization Guide lists ABA Services as prior authorization required. It does not split out the 97151 assessment, so confirm that code with UM at 855-798-4244.
Its manual says standard decisions take no more than 14 calendar days. Federal rules now cap standard Medicaid managed care decisions at 7 days for rating periods starting in 2026.
365 days from the date of service. Secondary claims with the primary insurer’s remittance are due within 180 days of that remittance.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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