Mississippi Administrative Code › Title 20 - Labor › Part 2 - Mississippi Workers' Compensation Medical Fee Schedule › BILLING AND REIMBURSEMENT RULES › Section 20-2-V - EXPLANATION OF REVIEW (EOR)

Current through June 25, 2024
A. Payers must
				provide an explanation of review (EOR) to health care providers for each bill
				whenever the payer's reimbursement differs from the amount billed by the
				provider, or when an original claim is altered or adjusted by the payer. The
				EOR must be provided within thirty (30) days of receipt of the bill, and must
				accompany any payment that is being made.
B. A payer may use the listed EOR codes and
				descriptors or may develop codes of their own to explain why a provider's
				charge has been reduced or disallowed, or why a claim has been altered or
				adjusted in some other way. In all cases, the payer must clearly and
				specifically detail the reasons for adjusting or altering a bill, including
				references to the applicable provisions of the Fee Schedule or CPT book, or
				other source(s) used as the basis for the EOR. Should the EOR include an
				alteration in the codes submitted on the original claim, it must be based on a
				review of the medical records documenting the service.
C. The EOR must contain appropriate
				identifying information to enable the provider to relate a specific
				reimbursement to the applicable claimant, the procedure billed, and the date of
				service.
D. Acceptable EORs may
				include manually produced or computerized forms that contain the EOR codes,
				written explanations, and the appropriate identifying information.
E. The following EOR codes may be used by the
				payer to explain to the provider why a procedure or service is not reimbursed
				as billed, provided clear and specific detail is included, along with
				references to the applicable provisions of the Fee Schedule or CPT book, or
				other source(s) used as the basis for the EOR:
001
These services are not reimbursable under the
								Workers' Compensation Law for the following reason(s): [Provide specific
								reason(s) why services are not reimbursable under the Workers' Compensation
								Law]
002
Charges exceed maximum allowable reimbursement
								[Specify]
003
Charge is included in the basic surgical allowance
								[Specify]
004
Surgical assistant is not routinely allowed for
								this procedure. Documentation of medical necessity required [Specify]
005
This procedure is included in the basic allowance
								of another procedure [Specify the other procedure]
006
This procedure is not appropriate to the diagnosis
								[Specify]
007
This procedure is not within the scope of the
								license of the billing provider [Specify]
008
Equipment or services are not prescribed by a
								physician [Specify]
009
This service exceeds reimbursement limitations
								[Specify]
010
This service is not reimbursable unless billed by a
								physician [Specify]
011
Incorrect billing form [Specify]
012
Incorrect or incomplete identification number of
								billing provider [Specify]
013
Medical report required for payment
								[Specify]
014
Documentation does not justify level of service
								billed [Specify]
015
Place of service is inconsistent with procedure
								billed [Specify]
016
Invalid procedure code [Specify]
017
Prior authorization was not obtained
								[Specify]