See the bold text below:

Rule 19.05 Definitions

(1) Adverse determination: A determination by a health insurance issuer that, based on the information provided, a request for a benefit under the health
insurance issuer’s health benefit plan upon application of any utilization review technique does not meet the health insurance issuer’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part, for the benefit; the denial, reduction, or termination of or failure to provide or make payment, in whole or in part, for a benefit based on a determination by a health insurance issuer that a preexisting condition was present before the effective date of coverage; or a rescission of coverage determination, which does not include a cancellation or discontinuance of coverage that is attributable to a failure to timely pay required premiums or contributions toward the cost of coverage.

(2) Appeal: A formal request, either orally or in writing, to reconsider an adverse determination.

(3) Approval: A determination by a health insurance issuer that a health care service has been reviewed and, based on the information provided, satisfies
the health insurance issuer’s requirements for medical necessity and appropriateness.

(4) Attending Physician: The physician with primary responsibility for the care provided to a patient in a hospital or other health care facility.

(5) Certificate: A certificate of registration granted by the Mississippi Insurance Department to a private review agent, and is not transferable. Any valid and active certificate issued by the Mississippi Department of Health prior to July 1, 2024, shall be honored by the Mississippi Department of Insurance until such time as the expiration or revocation of said certificate.

(6) Certification: A determination by a utilization review organization that an admission, extension of stay, or other medical service has been reviewed and based on the information provided, qualifies as medically necessary and appropriate under the medical review requirements of the applicable health benefit plan.

(7) Certification Number: The number assigned to each certified private review agent. This number is not transferable.

(8) Certified Private Review Agent: A private review agent who meets all the criteria for certification as set forth in these rules and regulations, has paid all current fees, and has been assigned a certification number.

(9) Chronic Condition. A medical condition that is medically complex, life threatening, long-term, or substantially disabling, including, but not limited to, chemotherapy for the treatment of cancer. Treatment for a chronic condition may include a recurring health care service or maintenance medication.

(10) Commissioner. The Commissioner of Insurance.

(11) Clinical review criteria: The written screening procedures, decision abstracts, clinical protocols and practice guidelines used by a health insurance issuer to determine the necessity and appropriateness of health care services.

(12) Concurrent Review: Utilization review conducted during a patient’s hospital stay or course of treatment.

(13) Consulting Physician: A Medical Doctor, Doctor of Osteopathy, Dentist, Psychologist, Podiatrist or Chiropractor who possess the degree of skill ordinarily possessed and used by members of his or her profession in good standing, and actively engaged in the same type of practice and relevant specialty. The medical and osteopathy specialist shall be certified by the Boards within the American Board of Medical Specialists or the American Board of Osteopathy.

(14) Department: The Mississippi Insurance Department.

(15) Emergency medical condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe
pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:

a. Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of any bodily organ or part.

(16) Emergency services: Health care items and services furnished or required to evaluate and treat an emergency medical condition.

(17) Enrollee: The individual who has elected to contract for, or participate in, a health benefit plan for their self and/or their dependents.

(18) Expedited Appeal: A request for additional review of a utilization review organization’s determination not to certify an admission, extension of stay, or
other medical service. An expedited appeal request may be called a reconsideration request by some utilization review organizations.

(19) Health care professional: A physician, a registered professional nurse or other individual appropriately licensed or registered to provide health care
services.

(20) Health care provider: Any physician, hospital, ambulatory surgery center, or other person or facility that is licensed or otherwise authorized to deliver
health care services.

(21) Health care service. Any services or level of services included in the furnishing to an individual of medical care or the hospitalization incident to the furnishing of such care, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing, or healing human illness or injury, including behavioral health, mental health, home health and pharmaceutical services and products.

(22) Health insurance issuer: Shall have the meaning given to that term in Miss. Code Ann. §83-9-6.3, and all private review agents and utilization review
plans, as both terms are defined in Miss. Code Ann. §41-83-1, with the exception of employee or employer self-insured health benefit plans under the federal Employee Retirement Income Security Act of 1974 or health care provided pursuant to the Workers’ Compensation Act.

(23) Hospital: An institution which is primarily engaged in providing to inpatients and outpatients, by or under the supervision of physicians, diagnostic services and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons, or rehabilitation services for the
rehabilitation of injured, disabled or sick persons, and also, means a place devoted primarily to the maintenance and operation of facilities for the
diagnosis, treatment and illness, disease, injury or deformity, or a place devoted primarily to providing obstetrical or other medical, surgical or nursing care of individuals, whether or not any such place be organized or operated for profit and whether any such place be publicly or privately owned. The term “Hospital” does not include convalescent or boarding homes, children’s homes, homes for the aged or other like establishments where room and board only are provided, nor does it include offices or clinics where patients are not regularly kept as bed patients. The term ”Hospital” includes Rural Emergency Hospitals which are licensed as such through the Mississippi Department of Health.

Medical Necessity-Definition

(24) Medically Necessary: A health care professional exercising prudent clinical judgment would provide care to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms and that are:

a. In accordance with generally accepted standards of medical practice; and

b. Clinically appropriate in terms of type, frequency, extent, site and duration and are considered effective for the patient’s illness, injury or disease; and not primarily for the convenience of the patient, treating physician, other health care professional, caregiver, family member or other interested party, but focused on what is best for the patient’s health outcome.

(25) Patient: The intended recipient of the proposed health care, his/her representative, and/or the enrollee.

(26) Physician: Any person with a valid doctor of medicine, doctor of osteopathy or doctor of podiatry degree.

(27) Physician Advisor: A physician representing the claim administrator/utilization review organization who provides advice on whether to certify an admission, extension of stay, or other medical service as being medically necessary and appropriate.

(28) Private Review Agent: A non-hospital affiliated person or entity performing utilization review on behalf of:

a. An employer or employees in the State of Mississippi; or

b. A third party that provides or administers hospital and medical benefits to citizens of this state, including: a health maintenance organization issued a certificate of authority under and by virtue of the laws of the State of Mississippi, or a health insurer, nonprofit health service plan, health insurance service organization, or preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state.

(29) Prior authorization: The process by which a health insurance issuer determines the medical necessity and medical appropriateness of an otherwise covered health care service before the rendering of such health care service. “Prior authorization” includes any health insurance issuer’s requirement that an enrollee, health care professional or health care provider notify the health insurance issuer before, at the time of, or concurrent to providing a health care service.

(30) Provider Utilization Review Representative: The person(s) in a physician’s office or hospital designated by the physician or hospital to provide the necessary information to complete the review process.

(31) Review Criteria: The written policies, decision rules, medical protocols, or guides used by the utilization review organization to determine certification [e.g., Appropriateness Evaluation Protocol (AEP) and Intensity of Service, Severity of Illness, Discharge, and Appropriateness Screens (ISD-A)].

(32) Urgent health care service: A health care service with respect to which the application of the time periods for making a non-expedited prior authorization that in the opinion of a treating health care professional or health care provider with knowledge of the enrollee’s medical condition:

a. Could seriously jeopardize the life or health of the enrollee or the ability of the enrollee to regain maximum function;

b. Could subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review; or

c. Could lead to likely onset of an emergency medical condition if the service is not rendered during the time period to render a prior authorization determination for an urgent medical service.

(33) Urgent health care service: For the purposes of this regulation, urgent health care service does not include emergency services.

(34) Utilization Review: A system for reviewing the appropriate and efficient allocation of hospital resources and medical services given or proposed to be
given to a patient or group of patients. More specifically, utilization review refers to pre-service determination of the medical necessity or appropriateness of services to be rendered in a hospital setting either on an inpatient or outpatient basis, when such determination results in approval or denial of payment for the services. It includes both prospective and concurrent review and may include retrospective review under certain circumstances.

(35) Utilization Review Plan: A description of the utilization review procedures of a private review agent.

Source: Miss. Code Ann. §41-83-1, et seq. (Rev. 2023); Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.09. Utilization Review Standards

(1) Responsibility for Obtaining Certification

a. In the absence of any contractual agreement to the contrary, the enrollee is responsible for notifying the private review agent in a timely manner and obtaining certification for health care services, if required by the health benefit plan. A private review agent shall allow any licensed health care provider, or responsible patient representative, including a family member, to assist in fulfilling that responsibility.

b. To ensure confidentiality, a private review agent must, when contacting a health care provider’s office or facility, or hospital, provide its certification number, the caller’s name, and professional qualification to the designated utilization review representative in the health care provider’s office or facility, or hospital.

(2) Information Upon Which Utilization Review is Conducted

a. When conducting routine prospective and concurrent utilization review, the private review agent shall collect only the information necessary to certify the admission, procedure or treatment and length of stay.

b. A private review agent should not routinely expect hospitals and physicians to supply numerically codified diagnoses or procedures. The private review agent may ask for such coding, since if it is known, its inclusion in the data collected increases the effectiveness of the communication.

c. The private review agent shall not routinely request copies of medical records on all patients reviewed. During prospective and concurrent review, copies of medical records should only be required when a difficulty develops in certifying the medical necessity or appropriateness of the admission or extension of stay. In those cases, only the necessary or pertinent sections of the record should be required.

d. Private review agents may request copies of medical records retrospectively for a number of purposes, including auditing the services provided, quality assurance, and evaluation of compliance with the terms of the health benefit plan or Utilization Review provisions. With the exception of the reviewing of records associated with an appeal or with an investigation of data discrepancies and unless otherwise provided for by contract or law, health care providers should be reimbursed the reasonable direct costs of duplicating requested records for retrospective review.

e. Private review agents must comply with prior authorization standards as established by Miss. Code Ann. §§ 83-5-901 through 83-5-937.

(3) Except as otherwise provided in these standards, a private review agent should limit its initial data requirements to the following elements:

a. Patient Information

i. Name

ii. Address

iii. Date of Birth

iv. Sex

v. Social Security Number or Patient ID Number

vi. Name of Carrier or Plan

vii. Plan ID Number

b. Enrollee Information

i. Name

ii. Address

iii. Social Security Number or Employee ID Number

iv. Relation to Patient

v. Employer

vi. Health Benefit Plan

vii. Group Number/Plan ID Number

viii. Other Coverage Available (Workers’ Comp., Medicare, etc.)

c. Attending Physician/Practitioner Information

i. Name

ii. Address

iii. Phone Number

iv. Degree

v. Specialty/Certification Status

vi. Tax ID or Other ID Number

d. Diagnosis/Treatment Information

i. Primary Diagnosis

ii. Secondary Diagnosis

iii. Proposed Procedure(s) or Treatment(s)

iv. Surgical Assistant Requirement

v. Anesthesia Requirement

vi. Proposed Admission or Service Date(s)

vii. Proposed Procedure Date

viii. Proposed Length of Stay

e. Clinical Information. Sufficient information for support of appropriateness and level of service proposed

f. Facility Information

i. Type (such as in-patient, out-patient, rehab, etc.)

ii. Status (DRG exempt status, as needed)

iii. Name

iv. Address

v. Phone Number

vi. Tax ID or Other ID Number

g. Concurrent (Continued Stay) Review Information

i. Clinical Contact Person

ii. Additional Days/Services Proposed

iii. Reasons for Extension

iv. Diagnosis (same/changed)

v. Clinical Information (Sufficient to support, as above)

h. Admissions to Facilities Other Than Acute Medical/Surgical Hospitals

i. History of Present Illness

ii. Patient Treatment Plan and Goals

iii. Prognosis

iv. Staff Qualifications

v. 24 Hour Availability of Staff

i. Compliance with prior authorization standards as established by Miss. Code Ann. §§ 83-5-901 through 83-5-937.

(4) Special Situations

a. Additional information may be required for other specific review functions such as discharge planning or catastrophic case management. Second opinion
information may also be required, when applicable, sufficient to support benefit plan requirements.

b. Information in addition to that described in this section may be requested by the private review agent or voluntarily submitted by the provider, when there is significant lack of agreement between the private review agent and health care provider regarding the appropriateness of certification during the review or appeal process. “Significant lack of agreement” means that the private review agent has:

i. Tentatively determined, through its professional staff, that a service cannot be certified;

ii. Referred the case to a physician for review; and

iii. Talked to or attempted to talk to the attending physician for further information.

c. A private review agent should share all clinical and demographic information on individual patients among its various divisions (e.g., certification, discharge planning, case management) to avoid duplicate requests for information from enrollee or providers.

(5) Procedures For Review Determination

a. Each private review agent shall have written procedures to ensure that reviews are conducted in a timely manner and as expeditiously as the enrollee’s condition requires.

b. Each private review agent shall make utilization reviews of prior authorization after obtaining all necessary information within pursuant to the timeframes establish in Rule 19.09(6) for nonurgent circumstances and Rule 19.09(7) for urgent circumstances, unless a longer minimum time frame is required under federal law for the health insurance issuer and the health care service at issue. Collection of the necessary information may necessitate a discussion with the attending physician or, based on the requirements of the health benefit plan, may involve a completed second opinion review.

c. A private review agent may review ongoing inpatient stays, but shall not routinely conduct daily review on all such stays. The frequency of the review for extension of the initial determination should vary based on the severity or complexity of the patient’s condition or on necessary treatment and discharge planning activity. Routine concurrent review generally should not be necessary earlier than 24 hours prior to the lapse of the certified length of stay.

d. Each private review agent shall have in place written procedures for providing notification of its determination regarding certification, recertification, or extensions of previously authorized length of stay in accordance with the following:

i. When an initial determination is made to certify, notification shall be provided promptly either by telephone or in writing, via letter or electronic mail, to the attending physician. The notification shall be transmitted in writing to the hospital and attending physician, as well as to the enrollee or patient, within two working days.

State Medical Necessity Decisions-Deadlines

ii. A determination to certify resulting from concurrent review shall be transmitted to the attending physician by telephone or in writing within one working day of receipt of all information necessary to complete the review process or prior to the end of the current certified period.

iii. If a private review agent transmits written confirmation of certification for continued hospitalization, that notification shall include the number of extended days, the new total number of days approved, and the date of admission.

iv. When a determination is made not to certify a hospital or surgery facility admission or extension of a hospital stay or other service requiring review determination, the attending physician shall be notified by telephone within one working day and a written notification should be sent within one working day to the hospital, attending physician and the enrollee or patient. The written notification shall include the principal reason(s) for the determination and the way to initiate an appeal of the determination if the enrollee, patient, or their representative so chooses. Reasons for a determination not to certify shall include, among other things, the lack of adequate information to certify after a reasonable attempt has been made to contact the attending physician.

State Medical Necessity Decisions-Deadlines

(6) Utilization review of prior authorizations in nonurgent circumstances.

If a health insurance issuer requires prior authorization of a health care service, the health insurance issuer must make an approval or adverse determination and notify the enrollee, the enrollee’s health care professional, and the enrollee’s health care provider of the approval or adverse determination as expeditiously as the enrollee’s condition requires but no later than seven (7) calendar days after obtaining all necessary information to make the approval or adverse determination, unless a longer minimum time frame is required under federal law for the health insurance issuer and the health care service at issue. As used in this section, “necessary information” includes the results of any face-to-face clinical evaluation, second opinion or other clinical information that is directly applicable to the requested service that may be required. Notwithstanding the foregoing provisions of this section, health insurance issuers must comply with the requirements of Miss. Code Ann. § 83-9-6.3 to respond by two (2) business days for prior authorization requests for pharmaceutical services and products.

(7) Utilization review of prior authorizations in urgent circumstances.

a. If requested by a treating health care provider or health care professional for an enrollee, a health insurance issuer must render an approval or adverse determination concerning urgent health care services and notify the enrollee, the enrollee’s health care professional and the enrollee’s health care provider of that approval or adverse determination as expeditiously as the enrollee’s condition requires but no later than forty-eight (48) hours after receiving all information needed to complete the review of the requested health care services, unless a longer minimum time frame is required under federal law for the health insurance issuer and the urgent health care service at issue.

b. To facilitate the rendering of a prior authorization determination in conformance with this section, a health insurance issuer must establish a mechanism to ensure health care professionals have access to appropriately trained and licensed clinical personnel who have access to physicians for consultation, designated by the plan to make such determinations for prior authorization concerning urgent care services.

(8) Notwithstanding language to the contrary elsewhere contained herein, if a licensed physician certifies in writing to an insurer within seventy-two (72) hours of an admission that the insured person admitted was in need of immediate hospital care for emergency services, such shall constitute a prima facie case of the medical necessity of the admission. To overcome this, the entity requesting the utilization review and/or the private review agent must show by clear and convincing evidence that the admitted person was not in need of immediate hospital care.

(9) Private review agents shall have in place written procedures to address the failure of a health care provider, patient, or their representative to provide the necessary information for review. If the patient or provider will not release the necessary information to the Utilization Review Organization, the Utilization Review Organization may deny certification in accordance with its own policy or that of the health benefit plan.

Source: Miss. Code Ann. §41-83-1, et. seq. (Rev. 2023); Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.10. Appeals of Determinations Not to Certify

(1) Each private review agent shall have in place procedures for appeals of determinations not to certify an admission, procedure, service or extension of stay. The right to appeal shall be available to the patient or enrollee, and to the attending physician on behalf of the patient. The procedures for appeals shall include, at a minimum, the following statement:

a. Any person aggrieved by a final decision of the department or a private review agent in a contested case under this act shall have the right of judicial appeal to the chancery court of the county of the residence of the aggrieved person.

b. Notwithstanding any provision of this act, the insured shall have the express right to pursue any legal remedies he may have in a court of competent jurisdiction.

(2) If a prior review agent has clear and convincing evidence that a health care professional or health care provider has knowingly and willingly submitted false or fraudulent requests for prior authorization to the health insurance issuer, the issuer shall notify and provide that the information in the manner as provided in Subsection (3) of this Section to the Commissioner of Insurance.

Amendments

(3) If a health insurance issuer intends either to implement a new prior authorization requirement or restriction or amend an existing requirement or restriction, the health insurance issuer shall provide contracted health care professionals and contracted health care providers of enrollees written notice of the new or amended requirement or amendment no less than sixty (60) days before the requirement or restriction is implemented. Written notice may take the form of a conspicuous notice posted on the health insurance issuer’s public website or portal for contracted health care professionals and contracted health care providers. A health insurance issuer shall provide email notices to health care professionals or health care providers if the health care professional or health care provider has requested to receive the notice through email. The health insurance issuer shall ensure that the new or amended requirement is not implemented unless the health insurance issuer’s website has been updated to reflect the new or amended requirement or restriction. Written notice of a new, amended, or restricted prior authorization requirement, as required by Miss. Code Ann. §83-5-909(6), may be provided less than sixty (60) days in advance if a health insurance issuer determines and contemporaneously notifies the department in writing and submitted to priorauthoriztion.notice@mid.ms.gov:

(a) The health insurance issuer has identified fraudulent or abusive practices related to the health care service;

(b) The health care service is unavailable or scarce which necessitates the use of an alternative health care service;

(c) The health care service is newly introduced to the health care market and a delay in providing coverage for the health care service and would not be in the best interests of enrollees;

(d) The health care service is the subject of a clinical trial authorized by the United States Food and Drug Administration; or

(e) Changes to the health care service or its availability are otherwise required by law to be made by the health insurance issuer in less than sixty (60) days.

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.11. Computation of Time

State Medical Necessity Decisions-Deadlines

(1) Utilization review of prior authorizations in nonurgent circumstances.

If a health insurance issuer requires prior authorization of a health care service, the health insurance issuer must make an approval or adverse determination and notify the enrollee, the enrollee’s health care professional, and the enrollee’s health care provider of the approval or adverse determination as expeditiously as the enrollee’s condition requires but no later than seven (7) calendar days after obtaining all necessary information to make the approval or adverse determination, unless a longer minimum time frame is required under federal law for the health insurance issuer and the health care service at issue. As used in this section, “necessary information” includes the results of any face-to-face clinical evaluation, second opinion or other clinical information that is directly applicable to the requested service that may be required. Notwithstanding the foregoing provisions of this section, health insurance issuers must comply with the requirements of Miss. Code Ann. § 83-9-6.3 to respond by two (2) business days for prior authorization requests for pharmaceutical services and products.

(2) Utilization review of prior authorizations in urgent circumstances.

a. If requested by a treating health care provider or health care professional for an enrollee, a health insurance issuer must render an approval or adverse determination concerning urgent health care services and notify the enrollee, the enrollee’s health care professional and the enrollee’s health care provider of that approval or adverse determination as expeditiously as the enrollee’s condition requires but no later than forty-eight (48) hours after receiving all information needed to complete the review of the requested health care services, unless a longer minimum time frame is required under federal law for the health insurance issuer and the urgent health care service at issue.

b. To facilitate the rendering of a prior authorization determination in conformance with this section, a health insurance issuer must establish a mechanism to ensure health care professionals have access to appropriately trained and licensed clinical personnel who have access to physicians for consultation, designated by the plan to make such determinations for prior authorization concerning urgent care services.

(3) Notwithstanding language to the contrary elsewhere contained herein, if a licensed physician certifies in writing to an insurer within seventy-two (72) hours of an admission that the insured person admitted was in need of immediate hospital care for emergency services, such shall constitute a prima facie case of the medical necessity of the admission. To overcome this, the entity requesting the utilization review and/or the private review agent must show by clear and convincing evidence that the admitted person was not in need of immediate hospital care.

(4) Notwithstanding the foregoing provisions of this Rule, health insurance issuers must comply with the requirements of Miss. Code Ann. § 83-9-6.2 to respond by two (2) business days for prior authorization requests for pharmaceutical services and products.

Source: Miss. Code Ann. §§41-83-1, et. seq; §83-9-6.2; Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.12. Urgent Prior Authorization Requests; Access to Physicians.

To facilitate an Urgent Prior Authorization request in a timely manner as required by statute and this Rule, a health insurance issuer must establish a policy to ensure Health Care Professionals, defined as a physician, registered professional nurse or other individual appropriately licensed or registered to provide health care services, have access to appropriately trained and licensed clinical personnel who have access to physicians for consultation, designated by the plan to make such determinations for prior authorization concerning urgent care services. This policy must include the following:

(1) Identification of the physicians available for consultation for each designated health service that requires prior authorization and contact information for those physicians.

(2) Time frame for physicians to respond to Health Care Professionals or other clinical personnel.

(3) Identification of the trained and licensed clinical personnel available for consultation for each designated health service that requires prior authorization and a method to contact said licensed clinical personnel. Identification may be made by providing the job title of the licensed clinical personnel.

(4) The expertise required by the consulting physicians, which should take into consideration the physician’s specialty and experience as determined by the health care services requiring Urgent Prior Authorization. This policy is separate from the requirement of use of physicians qualified to review appeals. Such
policy shall be submitted to the Department upon request.

Source: Miss. Code Ann. §41-83-1, et. seq Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.13. Notification for Adverse Determinations / Form

When a provider or facility makes a request for prior authorization, should a health insurance issuer make an adverse determination, the health insurance issuer shall include in writing the following in the notification to the enrollee, the enrollee’s health care professional, and the enrollee’s health care provider:

(1) The reasons for the adverse determination and related evidence-based criteria, including a description of any missing or insufficient documentation;

(2) The right to appeal the adverse determination;

(3) Instructions on how to file the appeal; and

(4) Additional documentation necessary to support the appeal.

A decision may be provided orally, but subsequent written notice must also be provided within twenty-four (24) hours of the oral decision. A denial must include the department and credentials of the individual who has the authorizing authority to approve or deny the request, including a phone number to contact the authorizing authority and a notice regarding the enrollee’s appeal rights and process. A health insurance issuer, when sending a notice to a covered person of a denial of a request for prior authorization made under this section, shall include with such notice the following statement in bold and in twelve (12) point font:

THE STATEMENT BELOW IS REQUIRED BY MISSISSIPPI INSURANCE DEPARTMENT REGULATION

ACTIONS YOU CAN TAKE AND HOW TO GET HELP

You, or someone on your behalf, recently requested approval from your health insurance plan for a health care service or item. Your health insurance plan
denied the request.

You have the right to ask your health insurance plan to change this decision. This is called an internal appeal. If the request is not approved after an internal appeal, your request may be eligible for a review by an independent third party. This is called an external review. The independent third party may
change your health insurance plan’s decision, or it may confirm your health insurance plan’s decision.

Please read carefully the information your health insurance plan has provided with this insert. This information explains the reason(s) for the health
insurance plan’s decision, as well as how to ask for an internal appeal or external review, including any deadlines and timing.

You should also feel free to contact your health insurance plan or the Mississippi Insurance Department to help you understand your rights and answer any questions. Contact information for both your health insurance plan and the Department is included in the information your health insurance plan has provided.

Source: Miss. Code Ann. §41-83-1, et. seq.; Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.14. Qualifications of persons reviewing appeals

1) A health insurance issuer must ensure that all appeals are reviewed by a physician when the request is by a physician or a representative of a physician. The physician must:

a. Possess a current and valid non-restricted license to practice medicine in any United States jurisdiction;

b. Be certified by the board(s) of the American Board of Medical Specialists or the American Board of Osteopathy within the relevant specialty of a physician who typically manages the medical condition or disease;

c. Be knowledgeable of, and have experience providing, the health care services under appeal;

d. Not have been directly involved in making the adverse determination; and

e. Consider all known clinical aspects of the health care service under review, including, but not limited to, a review of all pertinent medical records provided to the health insurance issuer by the enrollee’s health care professional or health care provider and any medical literature provided to the health insurance issuer by the health care professional or health care provider.

Source: Miss. Code Ann. §41-83-1, et. seq.; Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.15. Change of patient status to emergency status after submission of prior authorization request.

Notwithstanding language to the contrary elsewhere contained herein, if a licensed physician certifies in writing to an insurer within seventy-two (72) hours of an admission that the insured person admitted was in need of immediate hospital care for emergency services, such shall constitute a prima facie case of the medical necessity of the admission. To overcome this, the entity requesting the utilization review and/or the private review agent must show by clear and
convincing evidence that the admitted person was not in need of immediate hospital care.

Source: Miss. Code Ann. §41-83-21 (Rev. 2023); Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.16. Length of Approvals.

(1) A prior authorization approval shall be valid for the lesser of six (6) months after the date the health care professional or provider receives the prior authorization approval or the length of treatment as determined by the patient’s health care professional or the renewal of the policy or plan, and the approval period shall be effective regardless of any changes, including any changes in dosage for a prescription drug prescribed by the health care professional. Notwithstanding the foregoing, a health insurer and an enrollee or his/her health care professional may extend a prior authorization approval for a longer period by agreement. All dosage increases must be based on established evidentiary standards, and nothing in this section shall prohibit a health insurance issuer from having safety edits in place. This provision shall not apply to the prescription of benzodiazepines or Schedule II narcotic drugs, such as opioids.

(2) Nothing in this provision shall require a policy or plan to cover any care, treatment, or services for any health condition that the terms of coverage otherwise completely exclude from the policy’s or plan’s covered benefits without regard for whether the care, treatment or services are medically necessary.

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.17. Approvals for chronic conditions.

(1) If a health insurance issuer requires a prior authorization for a recurring health care service or maintenance medication for the treatment of a chronic or long-term condition, including, but not limited to, chemotherapy for the treatment of cancer, the approval shall remain valid for the lesser of twelve (12) months from the date the health care professional or health care provider receives the prior authorization approval or the length of the treatment as determined by the patient’s health care professional. Notwithstanding the foregoing, a health insurer and an enrollee or his or her health care professional may extend a prior authorization approval for a longer period, by agreement. This section shall not apply to the prescription of benzodiazepines or Schedule II narcotic drugs, such as opioids.

(2) Nothing in this section shall require a policy or plan to cover any care, treatment or services for any health condition that the terms of coverage otherwise completely exclude from the policy’s or plan’s covered benefits without regard for whether the care, treatment, or services are medically necessary.

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.18. Continuity of Prior Approvals.

(1) On receipt of information documenting a prior authorization approval from the enrollee or from the enrollee’s health care professional or health care provider, a health insurance issuer shall honor a prior authorization granted to an enrollee from a previous health insurance issuer for at least the initial ninety (90) days of an enrollee’s coverage under a new health plan, subject to the terms of the member’s coverage agreement.

(2) During the time period described in subsection (1) of this rule, a health insurance issuer may perform its own review to grant a prior authorization approval subject to the terms of the member’s coverage agreement.

(3) If there is a change in coverage or approval criteria for a previously authorized health care service, the change in coverage or approval criteria does not affect an enrollee who received prior authorization approval before the effective date of the change for the remainder of the enrollee’s plan year.

(4) Except to the extent required by medical exceptions processes for prescription drugs, nothing in this rule shall require a policy or plan to cover any care, treatment or services for any health condition that the terms of coverage otherwise completely exclude from the policy’s or plan’s covered benefits without regard for whether the care, treatment or services are medically necessary.

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.19. Revocations of prior authorizations.

(1) A health insurance issuer may not revoke or further limit, condition or restrict a previously issued prior authorization approval while it remains valid under this act.

(2) Notwithstanding any other provision of law, if a claim is properly coded and submitted timely to a health insurance issuer, the health insurance issuer shall make payment according to the terms of coverage on claims for health care services for which prior authorization was required and approval received before the rendering of health care services, unless one (1) of the following occurs:

(a) It is timely determined that the enrollee’s health care professional or health care provider knowingly and without exercising prudent clinical judgment provided health care services that required prior authorization from the health insurance issuer or its contracted private review agent without first obtaining prior authorization for those health care services;

(b) It is timely determined that the health care services claimed were not performed;

(c) It is timely determined that the health care services rendered were contrary to the instructions of the health insurance issuer or its contracted private review agent or delegated reviewer if contact was made between those parties before the service being rendered;

(d) It is timely determined that the enrollee receiving such health care services was not an enrollee of the health care plan; or

(e) The approval was based upon a material misrepresentation by the enrollee, health care professional, or health care provider; as used in this paragraph, “material” means a fact or situation that is not merely technical in nature and results or could result in a substantial change in the situation.

(3) Nothing in this section shall preclude a private review agent or a health insurance issuer from performing post-service reviews of health care claims for purposes of payment integrity or for the prevention of fraud, waste, or abuse.

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.20 Standardized electronic prior authorizations.

(1) By January 1, 2025, all health insurance issuer or designee utilization review organization shall make available a standardized electronic prior authorization request transaction process using an internet webpage, internet webpage portal, or similar electronic, internet, and web-based system.

(2) Not later than January 1, 2027, all health care professionals and health care providers shall be required to use the standardized electronic prior authorization request transaction process made available as required by subsection (1) of Rule 19.20.

(3) Not later than January 1, 2027, all health insurance issuers or designee utilization review organization shall comply with the Centers for Medicare & Medicaid Services, CMS-0057-F, Prior Authorization and Interoperability Final Rule (2024), regarding automation of prior authorization application programming interfaces.

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.21. Reports to the Department

(1) By June 1, 2025, and each June 1 after that date, a health insurance issuer shall report to the department, on a form issued by the department, the following aggregated trend data, de-identified of protected health information, related to the insurer’s practices and experience for the prior plan
year for health care services submitted for payment:

(a) The number of prior authorization requests;

(b) The number of prior authorization requests denied;

(c) The number of prior authorization appeals received;

(d) The number of adverse determinations reversed on appeal;

(e) Of the total number of prior authorization requests, the number of prior authorization requests that were not submitted electronically;

(f) The ten (10) health care services that were most frequently denied through prior authorization;

(g) The ten (10) reasons prior authorization requests were most frequently denied;

(h) The number of claims for health care services that were examined through a post-service utilization review process;

(i) The number and percentage of claims for health care services denied through post-service utilization review; and

(j) The ten (10) health care services that were most frequently denied as a result of post-service utilization reviews.

(k) Any prior authorization requirements that have been removed.

(2) All reports required by this section shall be considered public records under the Mississippi Public Records Act of 1983 and the Department shall make all reports freely available to requestors and post all reports to its public website without redactions.

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.22. Prior Authorization Statistics

Pursuant to Miss. Code Ann. §83-5-909(7), health insurance issuers using prior authorization shall make statistics available regarding prior authorization approvals and denials on their website in a readily accessible format. Following each calendar year, the statistics must be updated annually, by March 31, and include all of the following information:

(1) A list of all health care services, including medications, that are subject to prior authorization;

(2) The percentage of standard prior authorization requests that were approved, aggregated for all items and services;

(3) The percentage of standard prior authorization requests that were denied, aggregated for all items and services;

(4) The percentage of prior authorization requests that were approved after appeal, aggregated for all items and services;

(5) The percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved, aggregated for all items and services;

(6) The percentage of expedited prior authorization requests that were approved, aggregated for all items and services;

(7) The percentage of expedited prior authorization requests that were denied, aggregated for all items and services;

(8) The average and median time that elapsed between the submission of a request and a determination by the payer, plan or health insurance issuer, for standard prior authorization, aggregated for all items and services;

(9) The average and median time that elapsed between the submission of a request and a decision by the payer, plan or health insurance issuer, for expedited prior authorizations, aggregated for all items and services

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.23. Enforcement and administration

The Department may issue a cease-and-desist order or require a private review agent or health insurance issuer to submit a plan of correction for violation of Miss. Code Ann. §§ 83-5-901 through 83-5-937. The Department may impose upon a private review agent, health benefit plan or health insurance issuer an administrative fine not to exceed Ten Thousand Dollars ($10,000.00) per violation for failure to submit a requested plan of correction, failure to comply with its plan of correction, or repeated violations of this act. All hearings related to the enforcement and administration of this act shall be in accordance with 19 Miss. Admin. Code Part 1, Ch. 15, as may be amended from time to time. All fines collected by the Department under this section shall be deposited into the State General Fund. Upon receipt of a complaint by any person or his or her treating physician who has evidence that his or her health insurance issuer or health benefit plan is in violation of the provisions contained in Miss. Code Ann. §§ 83-5-901 through 83-5-937, these regulations, the Department shall review all complaints received and investigate all complaints that it deems a potential violation in accordance with normal Department policies and procedures and in a fair, efficient ant timely manner

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.23 24. Penalties

(1) A failure by a health insurance issuer to comply with the deadlines and other requirements specified in this act shall result in any health care services subject to review to be automatically deemed authorized by the health insurance issuer or its contracted private review agent.

(2) A private review agent, health benefit plan or health insurance issuer. The failure of a private review agent, health benefit plan or health insurance issuer to comply with the provisions of Miss. Code Ann. §§ 83-5-901 through 83-5-937 or the provisions of this Regulation shall subject said entity to the penalty provisions as provided in Miss. Code Ann. § 83-5-933.

Source: Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Rule 19.24 25. Severability

If any provision of this Regulation, or the application of the provision to any person or circumstance shall be held invalid, the remainder of the Regulation, and the application of the provision to persons or circumstances other than those to which it is held invalid, shall not be affected.

Source: Miss. Code Ann. § 83-5-1; § 83-41-413 (Rev. 2022).

Rule 19.25 26. Effective Date

This Regulation shall be effective on and after January 1, 2025.

Source: Miss. Code Ann. § 25-43-3.108 (Rev. 2022); Miss. C