Mississippi Administrative Code › Title 20 - Labor › Part 2 - Mississippi Workers' Compensation Medical Fee Schedule › BILLING AND REIMBURSEMENT RULES › Section 20-2-VI - REQUEST FOR RECONSIDERATION

Current through June 25, 2024
A. When, after
				examination of the explanation of review (EOR) and other documentation, a
				health care provider is dissatisfied with a payer's payment or dispute of a
				bill for medical services, reconsideration may be requested by the provider.
				Any other matter in dispute between the provider and payer may be subject to
				reconsideration as herein provided at the request of either party, including,
				but not limited to, a request by the payer for refund of an alleged
				over-payment. Alleged over-payments should be addressed through the dispute
				resolution process, if necessary, and not by way of unilateral recoupment
				initiated by the payer on subsequent billings.
B. A provider or payer must make a written
				request for reconsideration within thirty (30) days from the receipt of the
				explanation of review (EOR) or other written documentation evidencing the basis
				for the dispute. A request for reconsideration must be accompanied by a copy of
				the bill in question, the payers' explanation of review (EOR), and/or any
				additional documentation to support the request for reconsideration.
C. The payer or provider, upon receipt of a
				request for reconsideration, must review and re-evaluate the original bill and
				accompanying documentation, and, must notify the requesting party thirty (30)
				days thereafter of the results of the reconsideration. The response must
				adequately explain the reason(s) for the decision, and cite the specific basis
				upon which the final determination was made. If the payer finds the provider's
				request for reconsideration is meritorious, and that additional payment(s)
				should be made, or if the provider finds the payer's request for refund or
				other payment is meritorious, the additional payment should be made within the
				above thirty (30) day period. Any additional payment(s) made in response to a
				provider's or payer's request for reconsideration shall include interest from
				the original due date of the bill or payment, and an additional ten percent
				(10%) penalty if applicable.
D. If
				the dispute is not resolved within the above time after a proper request for
				reconsideration has been served by the provider or payer, then either party may
				request further review by the MWCC pursuant to the Dispute Resolution Rules set
				forth hereafter.
E. Failure to
				seek reconsideration within the time above provided shall bar and prohibit any
				further reconsideration or review of the bill or other issue in question
				unless, for good cause shown, the MWCC or its representative extends the time
				for seeking reconsideration or review under these rules. In no event shall the
				time for seeking reconsideration hereunder be extended by more than an
				additional thirty (30) days, and any such request for additional time in which
				to seek reconsideration or further review must be made in writing to the MWCC
				within the initial thirty (30) day period set forth in paragraph B. above.
F. Requests by either provider or
				payer for refunds, or for additional payment, or other requests related to the
				billing or payment of a claim, must be sought in accordance with the specific
				rules set forth herein. No retrospective audits or dispute requests shall be
				allowed beyond one year from the date of service for seeking reconsideration
				and/or review.