D.C. Mun. Regs. tit. 22, r. 22-B6005
Except as provided in § 6005.2, a member or member representative shall exhaust the insurer's internal grievance process prior to filing a request for an external review with the Director under this chapter. Medicaid recipients need not exhaust the internal grievance process and may appeal immediately to the Office of Fair Hearing.
A member or a member representative may file a grievance without first exhausting the insurer's internal review process in the case of an emergency or urgent medical condition, if the grievance demonstrates to the satisfaction of the Director a compelling reason to do so, including a showing that the potential delay in receipt of a health care service until after the member or member representative exhausts the internal grievance process could result in loss of life, serious impairment to a bodily function, serious dysfunction of a bodily organ, or the member remaining seriously mentally ill with symptoms that cause the member to be a danger to self and others, or the review is from an emergency grievance which the insurer has not resolved within twenty-four (24) hours, or when the insurer fails to meet timelines specified by the Act.
D.C. Mun. Regs. tit. 22, r. 22-B6005