Mississippi Administrative Code › Title 20 - Labor › Part 2 - Mississippi Workers' Compensation Medical Fee Schedule › AUTHORIZATION/PRE-CERTIFICATION RULES › Section 20-2-IV - PROCEDURES FOR REVIEW DETERMINATIONS

Current through June 25, 2024
The following procedures are required for effective review
				  determination.
A. Initial review
				determinations must be made within two (2) business days of receipt of the
				treating physician's records and other necessary information on a proposed
				non-emergency admission or service requiring a review determination. Receipt of
				necessary information may necessitate a discussion with the attending physician
				and may involve a completed second level clinical review. In the case of
				determinations made by a specialist conducting a second level clinical review
				as defined under the Authorization/Pre-Certification Rules of the Fee Schedule,
				the two (2) day period begins to run upon the payer's receipt of a completed
				second opinion review from the second level clinical reviewer. Second level
				clinical review is not an Employer's Medical Evaluation (EME). In an EME, the
				employee is examined. In contrast, a second level clinical review as defined
				under the Fee Schedule does not include an in-person examination of the
				employee. An EME conducted in lieu of pre-certification is governed by other
				provisions of the Authorization/Pre-Certification Rules of the Fee Schedule,
				Miss. Code Ann. Section
				71-3-15,
				and Miss. Work. Comp. Com. General Rule 1.9. In cases where an EME is conducted
				in lieu of pre-certification, the payer must notify the provider and the
				injured worker of its election to obtain an EME within the same (2) day period
				applicable to initial review determinations that begins once the payer has
				received the necessary information. However, in that instance, collection of
				the necessary information will not include the opinion of a second level
				clinical reviewer because no second level clinical reviewer will be used.
				Rather, the EME is elected in lieu of any further pre-certification. The
				Mississippi Workers' Compensation Commission Request for
				Authorization/pre-certification of Medical Treatment form may be used to
				request authorization/pre-certification.
B. When an initial determination is made to
				certify, notification shall be provided promptly, at least within one (1)
				business day or before the service is scheduled, whichever first occurs, either
				by telephone or by written or electronic notification to the provider or
				facility rendering the service. If an initial determination to certify is
				provided by telephone, a written notification of the determination shall be
				provided within two (2) business days thereafter. The written notification
				shall include the number of days approved, the new total number of days or
				services approved, and the date of admission or onset of services.
C. When a determination is made not to
				certify, notification to the attending or ordering provider or facility must be
				provided by telephone or electronic means within one (1) business day followed
				by a written notification within one (1) business day thereafter. The written
				notification must include the principal reason/clinical rationale for the
				determination not to certify, including specific reference to any provision of
				this Fee Schedule relied upon by the reviewer, and instructions for initiating
				an appeal and/or reconsideration request.
D. The payer or its review agent shall inform
				the attending physician and/or other ordering provider of their right to
				initiate an expedited appeal in cases involving emergency or imminent care or
				admission, or a standard appeal, as the case may permit, of a determination not
				to certify, and the procedure to do so.
1.
				Expedited appeal-When an initial determination not to certify a health care
				service is made prior to or during an ongoing service requiring imminent or
				expedited review, and the attending physician believes that the determination
				warrants immediate appeal, the attending physician shall have an opportunity to
				appeal that determination over the telephone or by electronic mail or facsimile
				on an expedited basis within one (1) business day.
a. Each private review agent shall provide
				for prompt and expeditious access to its consulting physician(s) for such
				appeals.
b. Both providers of care
				and private review agents should attempt to share the maximum information by
				phone, fax, or otherwise to resolve the expedited appeal (sometimes called a
				reconsideration request) satisfactorily.
c. Expedited appeals, which do not resolve a
				difference of opinion, may be resubmitted through the standard appeal process,
				or submitted directly to the Commission's Medical Cost Containment Division as
				a Request for Resolution of Dispute. A disagreement warranting expedited review
				or reconsideration does not have to be resubmitted to the payer or utilization
				review agent through the standard appeal process unless the requesting provider
				so wishes.