Mississippi Administrative Code › Title 19 - Department of Insurance › Part 3 - Accident and Health › Chapter 15 - Mississippi Health Carrier External Review Regulation › Rule 19-3-15.09 - External Review of Experimental or Investigational Treatment Adverse Determinations

Current through June 25, 2024
A.
1. Within four (4) months after the date of
				receipt of a notice of an adverse determination or final adverse determination
				pursuant to Rule 15.04 of this Regulation that involves a denial of coverage
				based on a determination that the health care service or treatment recommended
				or requested is experimental or investigational, a covered person or the
				covered person's authorized representative may file a request for external
				review with the Commissioner.
2.
a. A covered person or the covered person's
				authorized representative may make an oral request for an expedited external
				review of the adverse determination or final adverse determination pursuant to
				paragraph (1) if the covered person's treating physician certifies, in writing,
				that the recommended or requested health care service or treatment that is the
				subject of the request would be significantly less effective if not promptly
				initiated.
b. Upon receipt of a
				request for an expedited external review, the Commissioner immediately shall
				notify the health carrier.
c.
i. Upon notice of the request for expedited
				external review, the health carrier immediately shall determine whether the
				request meets the reviewability requirements of subsection B. The health
				carrier shall immediately notify the Commissioner and the covered person and,
				if applicable, the covered person's authorized representative of its
				eligibility determination.
ii. The
				Commissioner may specify the form for the health carrier's notice of initial
				determination under item (i) and any supporting information to be included in
				the notice.
iii. The notice of
				initial determination under item (i) shall include a statement informing the
				covered person and, if applicable, the covered person's authorized
				representative that a health carrier's initial determination that the external
				review request is ineligible for review may be appealed to the
				Commissioner.
d.
i. The Commissioner may determine that a
				request is eligible for external review under subsection B(2) notwithstanding a
				health carrier's initial determination the request is ineligible and require
				that it be referred for external review.
ii. In making a determination under item (i),
				the Commissioner's decision shall be made in accordance with the terms of the
				covered person's health benefit plan and shall be subject to all applicable
				provisions of this Regulation.
e. Upon receipt of the notice that the
				expedited external review request meets the reviewability requirements of
				subsection B(2), the Commissioner immediately shall assign an independent
				review organization to review the expedited request from the list of approved
				independent review organizations compiled and maintained by the Commissioner
				pursuant to Rule 15.11 of this Regulation and notify the health carrier of the
				name of the assigned independent review organization.
f. At the time the health carrier receives
				the notice of the assigned independent review organization pursuant to
				subparagraph (e) of this paragraph, the health carrier or its designee
				utilization review organization shall provide or transmit all necessary
				documents and information considered in making the adverse determination or
				final adverse determination to the assigned independent review organization
				electronically or by telephone or facsimile or any other available expeditious
				method.