District of Columbia program
Deadlines your plan has to meet
District-regulated plans have deadlines for answering requests to approve treatment.
What it is
District-regulated plans have deadlines for answering requests to approve treatment.
A complete request starts the District decision clock. The deadline depends on urgency and how the request was sent. A decision that misses the applicable deadline is deemed approved under District law.
Eligibility rules
- A policy, plan or contract regulated by the District, including the District employee preferred-provider and health-maintenance arrangements.
- Treated under a District-regulated plan.
What you get
- An urgent decision within 24 hours after the complete request.
- For other requests, 3 business days by portal or 5 by post, phone or fax.
Continuing treatment
- The District law also provides at least 90 days of continued treatment for serious illness when a treating clinician leaves the network.
- District employee preferred-provider and health-maintenance arrangements are expressly included in the approval statute.
If you decide to apply
- Ask your plan for the date it received everything needed and the deadline that follows.
- Ask the oncology team to document urgency when waiting would harm your child.
The plan, under District law · Official page ↗
Good to know
The decision clock starts with a complete request. The care team can document when it was sent and check whether a missed deadline counts as approval. Private self-funded work plans follow different rules.
Official sources
- D.C. Code § 31-3875.03 — Prior authorization decision time limits
- D.C. Code § 31-3875.01 — Prior authorization definitions
- D.C. Code § 44-303.01 — Continuity of care
- DC Office of Health Care Ombudsman and Bill of Rights
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
- Official source reviewed September 17, 2026 (B Q3)
“If our child is waiting for plan approval, when is the answer due? Could you help us check whether DC’s deadline applies and what happens if it is missed?”
Why I’m asking: I want to know whether our plan is covered by these rules and when an answer is due.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Get the completion date in writing and hold them to the clock.
Your social worker
The oncology team sends everything at once and marks urgent requests urgent.
The care team
The clinician marks the request urgent when waiting would harm the child.
- Who decides
- The plan, with the District's deadlines behind you.
- Ask the agency
- “When did you receive all the information for this request? District law gives you 24 hours for an urgent service and 3 business days by portal, and a decision after that is deemed approved.”
How to apply
First step: Ask the plan in writing for the date the request was complete.
- Ask the plan in writing for the date it had everything it asked for.
- Name the deadline back to them: 24 hours if urgent.
- If the deadline passes, say the service is deemed approved and ask for that in writing.
Official application / program page ↗
Where it starts: Ask the plan in writing for the date the request was complete and the deadline that follows from it.
What to gather
The diagnosis letter, the child’s insurance card, and the last two pay stubs cover most applications. The official page lists the rest.
How long: Twenty-four hours urgent, three business days by portal, five by post, phone or fax.
What a yes looks like
The approval, or written confirmation it is deemed approved.
What a no looks like, and the next move
Appeal inside the plan, then ask the District for an outside review.
Watch out
- The clock starts when the plan has everything it asked for, so get that date.
- Private employer self-funded plans follow federal rules instead.
If they say no, quote this: D.C. Code § 31-3875.03(b): "A health care service ... shall be deemed approved if the utilization review entity does not provide notice within the time frames provided."
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
Twenty-four hours for an urgent approval, three business days by portal. A late decision is deemed approved.
- $24 — Hours to decide an urgent request
- $3 — Business days to decide other requests sent through a portal
- $5 — Business days to decide other requests sent by post, phone or fax
- $90 — Days of continued treatment when a doctor leaves the network
Legal protection: A decision that misses the deadline is deemed approved · At least 90 days of continued treatment for a serious illness when a provider leaves the network
What it costs the family: Nothing.
The eligibility facts, as published
- Other
- A policy, plan or contract regulated by the District, including the District employee preferred-provider and health-maintenance arrangements
- Residency
- Treated under a District-regulated plan
The trap: The clock runs from when the plan has all the information it asked for, so make sure the team sent everything and get the date it was complete.
Where I read this
- D.C. Code § 31-3875.03 — Prior authorization decision time limits — Council of the District of Columbia, read September 10, 2026
- D.C. Code § 31-3875.01 — Prior authorization definitions — Council of the District of Columbia, read September 10, 2026
- D.C. Code § 44-303.01 — Continuity of care — Council of the District of Columbia, read September 10, 2026
- DC Office of Health Care Ombudsman and Bill of Rights — Government of the District of Columbia, read September 10, 2026