---
title: "MedStar Family Choice DC ABA coverage: the intake guide."
url: "https://carelu.com/payers/medstar-family-choice-district-of-columbia"
markdown_url: "https://carelu.com/payers/medstar-family-choice-district-of-columbia.md"
state: DC (District of Columbia)
payer: MedStar Family Choice District of Columbia
kind: Medicaid managed care plan (MCO)
parent_program: District of Columbia Medicaid (DC Healthy Families)
description: "How MedStar Family Choice DC handles ABA for DC Healthy Families children: prior authorization for ABA services, the UM line and fax, 14-day decisions, claims within 365 days, coordination of benefits and what intake should collect."
last_reviewed: October 2026
---

# MedStar Family Choice DC ABA coverage: the intake guide.

_Payer Guide · MedStar Family Choice · District of Columbia · Last updated October 2026 · 10 primary sources_

> DC Healthy Families plan whose Quick Authorization Guide lists "ABA Services" as prior authorization required.

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.

This plan administers the **District of Columbia Medicaid (DC Healthy Families)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [District of Columbia Medicaid guide](https://carelu.com/payers/district-of-columbia-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment** _(ask the plan)_: Treat as yes, but confirm: the Quick Authorization Guide (eff. 8/15/2026) lists "ABA Services — Prior Authorization Required" with no code-level split, so it does not say whether 97151 is included [1]
  - Ask the plan: MedStar Family Choice DC Utilization Management, 855-798-4244 (BH fax 202-243-6320): ask whether 97151 needs authorization.
- **Prior auth for treatment**: Yes. "ABA Services" appear under "Exceptions Requiring Prior Authorization" with "Prior Authorization Required" in the Quick Authorization Guide (effective 08/15/2026) [1]
- **Autism diagnosis required?**: Yes. The plan publishes no ABA criteria of its own, so the state rule applies: ASD services follow "an ASD diagnosis … determined through a diagnostic evaluation" (SPA 23-0009) [2][6]

## At a glance

- **Covers ABA?:** Yes, under DC Medicaid’s EPSDT ASD benefit for members under 21
- **Prior auth:** Required for "ABA Services" (Quick Authorization Guide, eff. 8/15/2026)
- **Submit via:** UM 855-798-4244; behavioral health fax 202-243-6320
- **Decision clock:** Manual: 14 calendar days standard; federal cap is 7 days from 1/1/2026 rating periods
- **Claims:** Within 365 days; EDI payer ID RP062; clean claims paid in 30 days
- **Network:** Provider Relations: MFCDC-ProviderRelations@MedStar.net, 800-261-3371

## Prior authorization and how requests are reviewed

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 and other insurance

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]

## Intake gates

The questions that decide whether a family can start with MedStar Family Choice District of Columbia, and what they have to bring.

- **Age limit**: Under 21. The plan covers ABA within DC Medicaid’s EPSDT ASD benefit (SPA 23-0009). [6][4]
- **Who may diagnose**: The plan publishes nothing different, so the state list applies: physician, PA, psychologist, psychology associate, LPC, LICSW or APRN (SPA 23-0009). [2][6]
- **Diagnostic tools required**: The plan names no instrument; the state requires "a validated assessment tool or instrument" (SPA 23-0009). [2][6]
- **Referral required?**: 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]
- **Telehealth**: 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 (who pays first)**: 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]
- **Prior-auth decision time** _(plan-dependent)_: 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.
- **Diagnosis recency** _(ask the plan)_: Not stated by the plan or the state. [2][6]
  - Ask the plan: MedStar Family Choice DC UM, 855-798-4244.

## Delivery and billing rules

Coverage decides whether MedStar Family Choice District of Columbia pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.
- **Daily limits / MUEs** _(ask the plan)_: 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.
- **Session-note signature** _(ask the plan)_: 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.
- **Place of service** _(ask the plan)_: The plan publishes no ABA setting rule. [2]
  - Ask the plan: MedStar Family Choice DC UM: ask which POS codes it pays for ABA.
- **Bill as provider** _(ask the plan)_: 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.

## What intake should collect for MedStar Family Choice District of Columbia

- **Member ID and plan:** Confirm MedStar Family Choice DC on the date of service.
- **Diagnostic evaluation:** ASD diagnosis by a DC-qualified diagnosing provider using a validated tool (state rule).
- **Treatment plan and codes:** Codes on the request must match what is billed; DC’s rule is a six-month plan with measurable goals and hours.
- **Other insurance:** Bill the primary first; MedStar needs the primary remittance within 180 days.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does MedStar Family Choice DC require prior authorization for ABA?

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.

### How long does MedStar Family Choice DC take to decide?

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.

### What is the timely filing limit?

365 days from the date of service. Secondary claims with the primary insurer’s remittance are due within 180 days of that remittance.

## Primary sources

1. [MedStar Family Choice DC — Quick Authorization Guide, DC Healthy Families (effective 08/15/2026)](https://www.medstarfamilychoicedc.com/-/media/project/mho/mfcdc/preauth_um/quick-authorization-guide-dc-healthy-families-plan_8-15-2026_web_excludingdrugs.pdf)
2. [MedStar Family Choice DC — DC Healthy Families Provider Manual (October 2025)](https://www.medstarfamilychoicedc.com/-/media/project/mho/mfcdc/provider-manual/mfc-dc-october-2025-provider-manual-102225.pdf)
3. [MedStar Family Choice DC — Utilization management (provider page)](https://www.medstarfamilychoicedc.com/providers/utilization-management)
4. [DHCF — Medicaid Managed Care Plans (MCPs): AmeriHealth Caritas DC, MedStar Family Choice DC, HSCSN (CASSIP)](https://dhcf.dc.gov/page/medicaid-managed-care-plans-mcps)
5. [DHCF Transmittal 26-19 (rev.) — Managed Care Plan Transition: Wellpoint DC enrollees to AmeriHealth Caritas DC (Aug. 6, 2026)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Transmittal%2026-19%20%28rev.%29%20-%20Managed%20Care%20Plan%20Transition.pdf)
6. [DC State Plan Amendment 23-0009 — Autism Spectrum Disorder services under EPSDT (approved Aug. 25, 2023; effective Oct. 1, 2023)](https://www.medicaid.gov/medicaid/spa/downloads/DC-23-0009.pdf)
7. [DHCF — Telemedicine Provider Guidance (January 2023, Transmittal 23-11)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/Telemedicine%20Provider%20Guidance_January%202023%20-%20Transmittal%2023-11.pdf)
8. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
9. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
10. [MedStar Family Choice DC — Provider News (provider newsletters and provider alerts)](https://www.medstarfamilychoicedc.com/Providers/Provider-Resources/Provider-News)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.