reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.11 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Current through June 25, 2024
The Division of Medicaid pays for all medically necessary
				  services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title
				  23, without regard to service limitations and with prior
				  authorization.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy) › Rule 23-213-3.1 - Provider Enrollment Requirements

Current through June 25, 2024
Providers of speech-language pathology must comply with the
				  requirements set forth in Part 200, Rule 4.8 in addition the provider type
				  specific requirements outlined below. Therapy providers wishing to enroll as
				  group providers must adhere to the enrollment requirements in Part 200, Rule
				  4.9.
A. National Provider Identifier
				(NPI), verification from National Plan and Provider Enumeration System (NPPES).
B. Copy of current licensure card
				or permit.
C. Documentation that
				the individual meets one (1) of the following requirements:
1. Has a certificate of clinical competence
				from the American Speech and Hearing Association (ASHA),
2. Has completed the equivalent educational
				requirements and work experience necessary for the certificate, or
3. Has completed the academic program and is
				acquiring supervised work experience to qualify for the certificate.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy) › Rule 23-213-3.2 - Definitions

Current through June 25, 2024
A. Medicaid defines speech therapy services
				as medically prescribed services necessary for the diagnosis and treatment of
				communication impairment and/or swallowing disorder that has occurred due to
				disease, trauma or congenital anomaly.
B. Medicaid defines a speech-language
				pathologist (speech therapist) as an individual who meets the state and federal
				licensing and/or certification requirements to perform speech-language
				pathology services.
C. Medicaid
				defines a speech-language pathology assistant or speech therapy assistant as an
				individual who meets the state and federal licensing and/or certification
				requirements to assist in the practice of speech-language pathology services
				under the supervision of a licensed speech-language pathologist.
D. Medicaid defines a speech-language
				pathology aide as an unlicensed individual who assists the speech-language
				pathologist and the speech-language pathology assistant in the practice of
				speech-language pathology. The speech-language pathology aide performs services
				under the supervision of the licensed speech-language pathologist.
E. Medicaid defines group therapy as the
				simultaneous treatment of two (2) or more beneficiaries.
F. Medicaid defines a prescribing provider as
				a state licensed physician, nurse practitioner, or physician assistant who
				refers the beneficiary for therapy services.
G. Medicaid defines maintenance therapy as
				activities that preserve the beneficiary's present level of function and
				prevent regression of that function.
Miss. Code Ann. §
										43-13-121;
				  42
				  CFR 440.110
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy) › Rule 23-213-3.5 - Prior Authorization/Pre-certification

Current through June 25, 2024
A. Medicaid
				requires prior authorization/precertification of certain outpatient therapy
				services. Prior authorization/precertification for therapy services is
				conducted through the Utilization Management and Quality Improvement
				Organization (UM/QIO) Failure to obtain prior authorization/precertification
				will result in denial of payment to the providers billing for
				services.
B. Prior
				Authorization/Pre-certification for outpatient therapy services is only
				required for certain procedure codes when the services fall into one (1) of the
				following categories:
1. Therapy services
				provided to beneficiaries, adult and/or children in individual therapist
				offices or in therapy clinics,
2.
				Therapy services provided to beneficiaries, adult and/or children in the
				outpatient department of hospitals,
3. Therapy services provided to
				beneficiaries, adult and/or children in physician offices/clinics,
4. Therapy services provided to beneficiaries
				in nursing facilities,
5. Therapy
				services covered under regular benefits and provided to beneficiaries also
				enrolled in a Home and Community-Based Services (HCBS) waiver
				program,
6. Therapy services
				provided to beneficiaries covered under both Medicare and Medicaid if Medicare
				benefits have been exhausted,
7.
				Therapy services provided to beneficiaries under age twenty-one (21) through
				the following providers: Rural Health Clinics (RHC), Federally Qualified Health
				Centers (FQHC), and State Department of Health, or
8. Therapy services billed by school
				providers.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy) › Rule 23-213-3.6 - Prescribing Provider Orders/Responsibilities

Current through June 25, 2024
A. Medicaid
				covers therapy services that are medically necessary, as certified by the
				prescribing provider. Medicaid defines prescribing provider as a state-licensed
				physician, nurse practitioner, or physician assistant who refers the
				beneficiary for therapy services.
B. The prescribing provider must complete a
				Certificate of Medical Necessity for Initial Referral/Orders form and submit it
				to the therapist prior to therapy evaluation.
C. Therapy services must be furnished
				according to a written plan of care (POC). The plan of care must be approved by
				the prescribing provider before treatment is begun. The review can be done in
				person, by telephone, or facsimile. An approved plan does not mean that the
				prescribing provider has signed the plan prior to implementation, only that
				he/she has agreed to it. The plan of care must be developed by a therapist in
				the discipline. A separate plan of care is required for each type of therapy
				ordered by the prescribing provider.
D. Medicaid requires the POC must, at a
				minimum, include the following:
1. Beneficiary
				demographic information,
2. Name of
				the prescribing provider,
3. Dates
				of service,
4.
				Diagnosis/symptomatology/conditions and related diagnosis codes,
5. Specific diagnostic and treatment
				procedures/modalities and related procedure codes,
6. Reason for referral,
7. Frequency of therapeutic
				encounters,
8. Duration of
				therapy,
9. Precautions, if
				applicable
10. Short and long term
				goals that are specific, measurable, and age appropriate,
11. Plan for the home program,
12. Discharge plan, and
13. Therapist's signature, including the name
				and title, and date of the therapy session,
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy) › Rule 23-213-3.7 - Evaluation/ Re-Evaluation

Current through June 25, 2024
A. Medicaid
				requires a Certificate of Medical Necessity for Initial Referral/Orders must be
				completed by the prescribing provider, and it must be received by the therapist
				prior to performing the initial evaluation. The evaluation does not require
				prior authorization.
B. Medicaid
				requires that before therapy is initiated, a comprehensive evaluation of the
				beneficiary's medical condition, disability, and level of functioning must be
				performed to determine the need for treatment and, when treatment is indicated,
				to develop the treatment plan. Medicaid requires the evaluation must be written
				and must demonstrate the beneficiary's need for skilled therapy based on
				functional diagnosis, prognosis, and positive prognostic indicators. The
				evaluation must form the basis for therapy treatment goals, and the therapist
				must have an expectation that the patient can achieve the established
				goals.
C. Initial evaluations
				should, at a minimum, contain the following information:
1. Beneficiary demographic
				information,
2. Name of the
				prescribing provider,
3. Date of
				the evaluation,
4.
				Diagnosis/functional condition or limitation being treated and onset
				date,
5. Applicable medical
				history: mechanism of injury, diagnostic imaging/testing, recent
				hospitalizations including dates, medications, co-morbidities, complicating or
				precautionary information,
6. Prior
				therapy history for same diagnosis/condition and response to therapy,
7. Level of function, prior and
				current,
8. Clinical status
				including cognitive function, sensation/proprioception, edema, vision and
				hearing, posture, active and passive range of motion, strength, pain,
				coordination, bed mobility, balance by sitting and standing, transfer ability,
				ambulation on level and elevated surfaces, gait analysis, assistive/adaptive
				devices currently in use or required, activity tolerance, presence of wounds
				including description and incision status, assessment of the beneficiary's
				ability to perform activities of daily living and potential for rehabilitation,
				age appropriate information on all children chronological age/corrected age,
				motivation for treatment, other significant physical or mental
				disabilities/deficiencies that may affect therapy,
9. Special/standardized tests including the
				name, scores/results, and dates administered,
10. Social history: effects of the disability
				on the beneficiary and the family, architectural/safety considerations present
				in the living environment, identification of the primary caregiver, caregiver's
				ability/inability to assist with therapy,
11. Discharge plan including requirements to
				return to home, school, and/or job,
12. Impression/interpretation of findings,
				and
13. Speech therapist's
				signature including name and title and date of service.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy) › Rule 23-213-3.8 - Maintenance Therapy

Current through June 25, 2024
A. Maintenance
				programs do not require the professional skills of a licensed therapy provider,
				are not considered medically necessary, and are not covered by Medicaid. Such
				services include, but are not limited to, the following:
1. Services related to the general welfare of
				the beneficiary such as exercises to promote fitness and flexibility, training
				or conditioning, and holistic treatments,
2. Repetitive services that are performed to
				maintain function, maintain gait, maintain strength and endurance that do not
				require the professional skills of a licensed therapy provider,
3. Therapy after the beneficiary has achieved
				goals outlined in the Plan of Care or where there is no meaningful progress,
				or
4. Exercises and range of motion
				exercises not related to the restoration of a specific loss of
				function.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy) › Rule 23-213-3.10 - Dual Eligibles

Current through June 25, 2024
A. Medicaid covers
				therapy services not covered by Medicare if the reason for the Medicare denial
				is other than for medical necessity. The therapy service must be prior
				authorization/precertified through the UM/QIO.
B. Beneficiaries cannot receive services
				under both programs simultaneously.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 3 - Outpatient Speech-Language Pathology (Speech Therapy) › Rule 23-213-3.11 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Current through June 25, 2024
The Division of Medicaid pays for all medically necessary
				  services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title
				  23, without regard to service limitations and with prior
				  authorization.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 4 - Administrative Appeals › Rule 23-213-4.1 - Appeals for Therapy Services

Current through June 25, 2024
A. Reconsideration
				Process - The beneficiary, therapy provider, or prescribing provider is
				afforded the right to appeal a utilization review denial to the UM/QIO through
				the reconsideration process set forth by the UM/QIO.
B. Administrative Appeal - Disagreement with
				the UM/QIO reconsideration determination shall be appealed to Medicaid by the
				beneficiary/legal representative. The beneficiary/legal representative must
				submit a written request for administrative appeal within thirty (30) calendar
				days of the UM/QIO reconsideration determination notice.
Miss. Code Ann. §
										43-13-121;
				  43-13-117;
				  42 CFR
				  441.308
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.1 - Provider Enrollment and Pharmacy Participation

Current through June 25, 2024
A.
				Pharmacists must comply with the requirements set forth in Part 200, Chapter 4,
				Rule 4.8 for all providers in addition to the provider type specific
				requirements that follow:
1. National
				Provider Identifier (NPI), verification from National Plan and Provider
				Enumeration System (NPPES),
2.
				Written confirmation from the IRS confirming the tax identification number and
				legal business name, and
3. Copy of
				current pharmacy permit issued by the Mississippi Board of Pharmacy.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.2 - Pharmacy Services

Current through June 25, 2024
A. The Division of
				Medicaid covers the following pharmacy services including, but not limited to:
1. Prescription drug coverage which includes
				all legend prescription drugs manufactured by a company that has signed a drug
				rebate agreement with certain specific Centers for Medicare and Medicaid
				Services (CMS) exceptions.
2.
				Over-the-counter (OTC) drug coverage which is limited to OTC drugs listed on
				the OTC Formulary.
3. Immunization
				coverage which includes certain vaccines. [Refer to Miss. Admin. Code Part 224,
				Rule 1.7 ].
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.3 - Drugs Subject to Exclusion or Otherwise Restricted

Current through June 25, 2024
A. The
				Division of Medicaid does not cover pharmacy benefits for full benefit, dual
				eligible individuals who are entitled to receive Medicare benefits under Part
				A, B, or C, except for drugs in the Medicare excluded categories.
B. Medicaid excluded or otherwise restricted
				drugs include, but are not limited to:
1.
				Drugs when used for anorexia, weight loss, or weight gain, except selected
				drugs used to treat obesity.
2.
				Drugs when used to promote fertility,
3. Drugs when used for cosmetic purposes or
				hair growth,
4. Over-the-counter
				(OTC) items except those listed on the Division of Medicaid's OTC formulary
				which are assigned an appropriate National Drug Code (NDC) on their label and
				are manufactured by a company that has signed a rebate agreement,
5. Drugs when used for the symptomatic relief
				of cough and colds except for cough and/or cold drugs listed on the OTC
				formulary and benzonatate,
6.
				Prescription vitamins and mineral products except for:
a) Prenatal vitamins,
b) Folic acid, and
c) Cyanocobalamin (vitamin B12)
				injections.
7. Covered
				outpatient drugs which the manufacturer requires, as condition of sale, that
				associated tests or monitoring services be purchased exclusively from the
				manufacturer or its designee,
8.
				Those drugs designated less than effective by the Federal Drug Administration
				(FDA) as a result of the Drug Efficacy Study Implementation (DESI) program
				unless provided through expanded EPSDT services in Miss. Admin. Code Part
				223.
9. [Deleted eff.
				01/01/2014],
10. [Deleted eff.
				01/01/2014],
11. Drugs when used
				for the treatment of sexual or erectile dysfunction, unless such drugs are used
				to treat a condition, other than sexual or erectile dysfunction, for which the
				drugs have been approved by the FDA.
12. Drugs that are investigational or
				approved drugs used for investigational purposes,
13. Drugs used for off-label indications
				which are not found in official compendia or generally accepted in peer
				reviewed literature,
14. Drugs
				dispensed after the expiration date,
15. Drugs classified as herbal and/or
				homeopathic products,
16. Moved to
				Miss. Admin. Code Part 214, Chapter 1, Rule
				1.3.C,
17. Drugs produced by manufacturers that do
				not have signed rebate agreements with the federal government as required by
				the Omnibus Budget Reconciliation Act (OBRA) of 1990, unless provided through
				expanded EPSDT services in Miss. Admin. Code Part 223, and
18. Compounded prescriptions except for
				hyperalimentation. The Division of Medicaid defines compounded prescriptions as
				mixtures of two or more ingredients.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.4 - Prior Authorization

Current through June 25, 2024
A. The Division of
				Medicaid requires prior authorization of certain covered drugs to ensure use as
				approved by the Food and Drug Administration (FDA) for specific medical
				conditions.
1. Prior authorization of drugs
				must be obtained from the Division of Medicaid's Pharmacy Prior Authorization
				Unit or its designee before the drug may be dispensed.
2. All prior authorization requests must be
				submitted electronically via web-portal or by facsimile.
3. Only the Mississippi Medicaid enrolled
				prescribing provider or a member of the provider's staff may request prior
				authorization.
4. Prior
				authorization requests submitted by agents of drug manufacturers will be
				denied.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.5 - Reimbursement

Current through June 25, 2024
The Division of Medicaid reimburses for certain legend and
				  non-legend drugs:
A. As authorized
				under the State Plan,
B.
				Prescribed by a Mississippi Medicaid enrolled prescribing provider licensed to
				prescribe drugs, and
C. Dispensed
				by a Mississippi Medicaid enrolled pharmacy in accordance with Federal and
				State laws.
42 U.S.C. §
											1396a(a)(30)(A); 42 C.F.R.
				  § 447.332; Miss. Code Ann. §§
										43-13-121,
				  73-21-155.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.6 - Prescription Requirements

Current through June 25, 2024
A. Pharmacists in
				the legal employ of the pharmacy provider or under the personal direction of a
				pharmacist employed by the pharmacy provider must submit claims for services
				rendered. Prescriptions must be dispensed at the provider's actual physical
				location of the pharmacy.
B. For
				purposes of this rule, the Division of Medicaid defines a prescribing provider
				as an enrolled Mississippi Medicaid provider duly licensed and acting within
				the scope of practice of his/her profession according to State law.
C. All non-electronic prescriptions must be
				written on tamper-resistant pads/paper in order to be eligible for
				reimbursement by the Division of Medicaid.
1.
				The tamper-resistant prescription pads/paper requirement applies to all
				Medicaid prescribing providers including physicians, dentists, optometrists,
				nurse practitioners and other providers who prescribe outpatient drugs
				including over-the-counter drugs.
2. Exemptions to this mandate include:
a) Prescriptions presented by other modes of
				transmission including facsimile, electronic or e-prescribed, and telephone,
b) Written orders prepared in an
				institutional setting, including intermediate care facilities and nursing
				facilities, provided that the beneficiary never has the opportunity to handle
				the written order and the order is given by licensed staff directly to the
				dispensing pharmacy, or
c) Transfer
				of a prescription between two (2) pharmacies, provided that the receiving
				pharmacy is able to confirm by facsimile or telephone call the authenticity of
				the tamper-resistant prescription with the original pharmacy.
3. Pharmacy providers
				must return all funds to the Division of Medicaid for any dispensed
				prescription which is written hard copy on a non-tamper-resistant pad/paper.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.7 - Refills/Renewals of Prescription Drugs

Current through June 25, 2024
A. A written,
				faxed, e-prescribed, or telephoned prescription may be refilled, in compliance
				with the prescriber's order, up to a limit of eleven (11) times per year, if
				compliant with state and/or federal regulations and guidelines. Additionally,
				the following are applicable:
1. The absence
				of an indication to refill by the prescribing provider renders the prescription
				non-refillable.
2. Refills are
				reimbursable only if specifically authorized by the prescribing provider.
3. The Division of Medicaid does
				not reimburse prescription refills:
a)
				Exceeding the specific number authorized by the prescribing provider.
b) Dispensed after one (1) year
				from the date of the original prescription.
c) With greater frequency than the
				approximate interval of time that the dosage regimen of the prescription would
				indicate, unless extenuating circumstances are documented which would justify
				the shorter interval of time before the refilling of the prescription.
d) With quantities in excess of
				the prescribing provider's authorization.
e) Without an explicit request from a
				beneficiary or the beneficiary's responsible party, such as a caregiver, for
				each filling event. The possession, by a provider, of a prescription with
				remaining refills authorized does not in itself constitute a request to refill
				the prescription.
f) Until
				seventy-five percent (75%) of the day's supply of the non-controlled substance
				has elapsed as indicated on the prescription.
g) For any controlled substance (Schedule
				III, IV, and V) until eighty-five percent (85%) of the day's supply of the drug
				has elapsed as indicated on the prescription. Any attempt to refill a
				prescription through the Point-of-Sale system before the twenty-sixth (26th)
				day will be automatically denied.
h) For Schedule II controlled substances.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.8 - Generic Mandates for Prescription Drugs

Current through June 25, 2024
Mississippi law requires that the Division of Medicaid does
				  not reimburse for a brand name drug if an equally effective generic equivalent
				  is available and the generic equivalent is the least expensive.
A. Generic drugs classified as non-preferred
				by the Division of Medicaid require prior authorization.
B. In the absence of a specific request for
				the brand name drug from the prescribing provider to the pharmacist, the
				pharmacist must follow standard practice guidelines for the State of
				Mississippi and fill the prescription with the generic equivalent unless the
				branded agent is preferred and the generic agent is non-preferred.
C. Prior authorization (PA) is required for
				any brand name multiple source drug that has a generic equivalent except Narrow
				Therapeutic Index (NTI) drugs as defined by the Division of Medicaid.
Miss. Code Ann.
				  §§
										43-13-117,
				  73-21-115,
				  73-21-117,
				  73-21-123,
				  73-21-127,
				  73-21-129.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.9 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Current through June 25, 2024
The Division of Medicaid pays for all medically necessary
				  services for EPSDT-eligible beneficiaries in accordance with Miss. Admin. Code,
				  Part 223, without regard to service limitations and with prior
				  authorization.
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.10 - Preferred Drug List

Current through June 25, 2024
A. The Division of
				Medicaid recommends that prescribers use the drugs on the Preferred Drug List
				(PDL).
1. The PDL is defined as a list of
				drugs reviewed and proposed by the Pharmacy and Therapeutics (P&T)
				Committee, a group of physicians, pharmacists, nurse practitioners, and/or
				other health care professionals. Final approval of the PDL is the
				responsibility of the Executive Director of the Division of Medicaid.
2. The PDL contains a wide range of generic
				and preferred brand name products approved by the FDA.
3. A medication becomes a preferred drug
				based first on safety and efficacy, then on cost-effectiveness.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.11 - Smoking Cessation Agents

Current through June 25, 2024
The Division of Medicaid covers all FDA approved smoking
				  cessation OTC and prescription drugs and nicotine replacement products when
				  used to promote smoking cessation, except dual eligible as Part D will
				  cover.
Miss. Code Ann §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.12 - Beneficiary Signature

Current through June 25, 2024
A. The pharmacy
				must obtain the signature of beneficiary or his/her representative signature
				and their relationship to the beneficiary for each prescription received with
				the exception of beneficiaries living in long-term care facilities, i.e.
				nursing facilities, intermediate care facilities for the intellectually
				disabled (ICF/IID), psychiatric residential treatment facilities (PRTF) and/or
				nursing facilities for the severely disabled (NFSD).
1. Electronic signatures are
				acceptable.
2. One signature per
				prescription is required.
3. The
				pharmacist may sign for a prescription if the beneficiary or his/her
				representative is not capable of signing. When signing the pharmacist must:
a. Document the circumstances preventing the
				beneficiary or his/her representative from signing for the prescription,
				and
b. Sign the prescription
				signature record with his/her own name and the beneficiary's name.
4. For shipped or delivered
				prescriptions, the pharmacy must obtain the signature of the beneficiary or
				his/her representative and their relationship to the beneficiary.
a. The pharmacy must maintain signatures
				on-site and in an auditable manner.
b. The Division of Medicaid will not
				reimburse for medications lost in transit and/or not received by the
				beneficiary.
c. During a national
				or statewide emergency, a signature is not required.
1) The provider must document the
				emergency.
2) The provider must
				document confirmation of delivery by an alternate means including, but not
				limited to:
(a) Telephone,
(b) Text message, or
(c) Other electronic communication.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.13 - Retrospective Drug Utilization Review (DUR)

Current through June 25, 2024
A. The Division of
				Medicaid utilizes a quality assurance program, Drug Utilization Review (DUR),
				to:
1. Promote patient safety by an increased
				review and awareness of outpatient prescribed drugs including drug
				appropriateness,
2. Enhance and
				improve the quality of pharmaceutical care and patient outcomes by encouraging
				optimal drug use, and
3. Educate
				physicians and pharmacists on appropriate, safe and effective drug
				therapy.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.14 - Participating Federally Qualified Health Center (FQHC) Providers

Current through June 25, 2024
All drugs, as defined by the Veterans Health Care Act of 1992
				  Title VI, purchased by an in house pharmacy of a Federally Qualified Health
				  Center (FQHC) at a discounted price must be reported on the cost report and are
				  reimbursed through the core services encounter rate and not billed through the
				  Pharmacy Program.
The Veterans Health
				  Care Act of 1992 Title VI.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.15 - 340B Program

Current through June 25, 2024
Providers participating in the 340B program must adhere to
				  all the provisions in Miss. Admin. Code Part 200, Chapter 4, Rule
				  4.10.
Sec. 340B of the Public
				  Health Service Act ( Pub.
				  L. 102-585 ), as amended by the Patient Protection
				  and Affordable Care Act ( Pub. L. 111-148 ), Health Care
				  and Education Reconciliation Act (
				  Pub. L.
				  111-152 ) and Medicare and Medicaid Extenders Act
				  of 2010 ( Pub. L.
				  111-309 ); Miss. Code Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 1 - General Pharmacy › Rule 23-214-1.16 - Clinician Administered Drugs and Implantable Drug System Devices (CADDs)

Current through June 25, 2024
A. The Division of Medicaid defines Clinician
				Administered Drugs and Implantable Drug System Devices (CADDs) as certain
				physician-administered drugs, with limited distribution or limited access for
				beneficiaries and administered in an appropriate clinical setting, which may be
				billed as either a medical claim or pharmacy point-of-sale (POS) claim, as
				determined by the Division of Medicaid.
B. The Division of Medicaid covers certain
				CADD drugs which are listed on the Division of Medicaid's website.
C. CADD drugs which are dispensed by a
				pharmacy provider directly to a prescriber for administration do not count
				toward a beneficiary's monthly prescription drug limits.
Miss. Code
				  Ann. §§
										43-13-117,
				  43-13-121; MS SPA
				  2018-0011.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 214 - Pharmacy Services › Chapter 2 - Pharmacy Disease Management › Rule 30-214-2.1 - Provider Enrollment and Pharmacy Participation

Current through June 25, 2024
A.
				Pharmacists participating in the Medicaid program and providing disease
				management services must comply with the requirements outlined in Part 214,
				Chapter 1, Rule 1.1 in addition to the following requirements:
1. National Provider Identifier (NPI)
				verification from National Plan and Provider Enumeration System
				(NPPES),
2. Copy of current
				pharmacist's license or permit,
3.
				Verification of social security number using a social security card, driver's
				license if it notes the social security number, military ID or a notarized
				statement signed by the provider noting the social security number. The name
				noted on verification must match the name on the W-9, and
4. Credentials from a nationally recognized
				credentialing agency applicable to the specific disease for which care is
				provided.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.1 - Definitions

Current through June 25, 2024
The Division of Medicaid defines:
A. Home health services as skilled nursing
				visits, home health aide visits, and durable medical equipment, supplies and
				appliances provided to a beneficiary:
1. At
				the beneficiary's place of residence,
2. Ordered by the beneficiary's physician or
				non-physician practitioner (NPP) as part of a written plan of care reviewed by
				the physician or NPP every sixty (60) days.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.2 - Provider Enrollment Requirements

Current through June 25, 2024
Home health providers, including out-of-state providers,
				  must satisfy all requirements set forth in Part 200, Rule 4.8 in addition to
				  the following provider type specific requirements:
A. National Provider Identifier (NPI),
				verification from National Plan and Provider Enumeration System
				(NPPES).
B. Written confirmation
				from the Internal Revenue Service (IRS) confirming the provider's tax
				identification number and legal business name.
C. A copy of the provider's current Medicare
				certification or Tie-In Notice from the Medicare Intermediary. An Explanation
				of Medicare Benefits (EOMB) is not acceptable.
D. A copy of License from the Mississippi
				State Board of Health, Health Facilities Licensure and Certification. If parent
				entity is an out-of-state facility with a servicing location in Mississippi, a
				copy of the respective State's license is required.
42 C.F.R. §
											440.70, 42 C.F.R. Part 455, Subpart E; 42
				  C.F.R. Part 484; Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.3 - Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid covers the following home health services:
1. Skilled nursing visits.
a Intermittent or part-time skilled nursing
				services must be provided during the visit by a registered nurse (RN) employed
				by a home health agency in accordance with Mississippi State Department of
				Health, Division of Health Facilities Licensure and Certification (MSDH-DHFLC)
				standards or an RN when no home health agency exists in the area.
b The RN must be a graduate of an approved
				school of professional nursing, who is licensed as an RN by the State in which
				they practice.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.4 - Non-Covered Services

Current through June 25, 2024
The Division of Medicaid does not cover:
A. Home health services provided to a
				beneficiary who can receive the services in an outpatient setting including,
				but not limited to:
1. Outpatient
				hospital,
2. Free-standing clinic,
				or
3. Nursing facility.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.5 - Reimbursement

Current through June 25, 2024
A. In order to receive reimbursement from the
				Division of Medicaid for the face-to-face encounter, the encounter must be
				conducted by an enrolled Medicaid provider.
B. The Division of Medicaid reimburses for
				home health services based on reasonable cost determined in accordance with the
				State Plan and Medicare principles of reimbursement, except when Medicare
				guidelines are contradictive to directives of the State Plan or the Division of
				Medicaid. In such a situation, the State Plan or the Division of Medicaid will
				prevail.
1. Medicaid cost reporting schedules
				must be included with the Medicare cost report to compute Medicaid
				reimbursement.
2. A schedule must
				be completed to reflect the lower of reasonable costs or customary charge
				provisions as they apply to Medicaid.
3. In addition to the lower of costs or
				charge limitations, reimbursement for home health services is limited to and
				cannot exceed the prevailing costs of providing nursing facility
				services.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.6 - Documentation

Current through June 25, 2024
A. The Division of Medicaid requires the home
				health agency to maintain auditable records that substantiate the services
				provided and include, at a minimum, the following in each beneficiary's record
				verifying services provided by the home health agency are medically necessary
				[Refer to Maintenance of Records Part 200, Rule
				1.3.]:
1. Physician or non-physician practitioner
				(NPP) referral,
2. Appropriate
				information identifying the beneficiary,
3. Name of the physician or NPP,
4. Documentation of the face-to-face
				encounter with the ordering physician or allowed nonphysician practitioner
				(NPP) including:
a) Documentation that the
				required face-to-face encounter related to the primary reason the beneficiary
				needs the services occurred ninety (90) days before or thirty (30) days after
				the start of home health services,
b) Identification of the physician or allowed
				NPP who conducted the encounter, and
c) The date of the face-to-face
				encounter,
5. If the
				face-to-face encounter was performed by an allowed NPP, the clinical findings
				of the face-to-face encounter must be incorporated into a written or electronic
				document in the beneficiary's medical record.
6. Documentation that the services cannot be
				provided in any other setting other than the beneficiary's residence.
7. The initial order and all recertifications
				signed by the physician or NPP which must include:
a) Justification home health services are
				medically necessary and reasonable for treatment of the beneficiary's illness,
				injury, or condition,
b) The type
				of services required, and
c) The
				estimated duration home health services will be needed,
8. The beneficiary's plan of care,
9. Documentation that the beneficiary's plan
				of care is reviewed and recertified by a physician or NPP every sixty (60)
				days,
10. Signed copy of orders,
				new orders or changes in orders for medications, medical supplies, treatments,
				dietary, and activities,
11. Case
				conference report(s) covering all disciplines,
12. Lab results and other diagnostic test
				results,
13. Discharge summary to
				include transfers and hospital stays,
14. Documentation of all verbal
				communications between the home health agency and the physician and/or allowed
				NPP, and
15. Documentation that a
				supervisory visit was made by a registered nurse (RN) at least every sixty (60)
				days for home health aide services.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.7 - Early, Periodic Screening, Diagnosis and Treatment (EPSDT)

Current through June 25, 2024
A. The Division of Medicaid covers all
				medically necessary services for beneficiaries who qualify for the federally
				mandated Early, Periodic Screening, Diagnosis and Treatment (EPSDT) program
				without regard to service limitations and with prior authorization.
B. Physical therapy, speech-language
				pathology and audiology services are reimbursed on a fee-for-service basis at
				an all-inclusive, per visit rate plus a medical supply add-on calculated as
				described in the State Plan.
42 C.F.R. §
											440.70; Miss. Code Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.8 - Dual Eligibles

Current through June 25, 2024
Beneficiaries eligible for Medicare and Medicaid must not
				  receive home health visits under both programs simultaneously. Refer to Part
				  200, Chapter 2, Rule 2.3.
A. If
				Medicare does not cover home health nurse visits, physical therapy visits, or
				speech therapy visits because skilled services are not being provided, the
				Division of Medicaid will not cover the services.
B. If Medicare does not cover home health
				aide visits because a skilled service is not being provided, the Division of
				Medicaid will cover medically necessary aide visits.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.9 - Reimbursement

Current through June 25, 2024
A. The Division of Medicaid covers home
				health agency reimbursement for covered services based on reasonable cost which
				is determined in accordance with the Mississippi Medicaid Home Health
				Reimbursement Plan and Title XVIII (Medicare) principles of reimbursement,
				except when Medicare guidelines are contradictive to directives of the State
				Plan or Division of Medicaid. In such a situation, the State Plan or Division
				of Medicaid will prevail.
1. Medicaid cost
				reporting schedules must be included with the Medicare cost report to compute
				Medicaid reimbursement.
2. A
				schedule must be completed to reflect the lower of reasonable costs or
				customary charge provisions as they apply to Medicaid.
3. In addition to the lower of costs or
				charge limitations, reimbursement for home health services is limited to and
				cannot exceed the prevailing costs of providing nursing facility services in
				the Mississippi Medical Assistance (Medicaid) Program.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 215 - Home Health Services › Chapter 1 - Home Health Services › Rule 23-215-1.10 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Current through June 25, 2024
The Division of Medicaid pays for all medically necessary
				  services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title
				  23, without regard to service limitations and with prior
				  authorization.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 216 - Dialysis Services › Chapter 1 - Dialysis Services › Rule 23-216-1.1 - Provider Enrollment Requirements

Current through June 25, 2024
Freestanding or hospital-based kidney dialysis centers must
				  satisfy all requirements set forth in Miss. Admin. Code, Part 200, Chapter 4,
				  Rule 4.8, in addition to the following provider type specific
				  requirements:
A. National Provider
				Identifier (NPI), verification from National Plan and Provider Enumeration
				System (NPPES),
B. Written
				confirmation from the IRS confirming the providers tax identification number
				and legal name, and
C. Copy of
				dialysis Medicare certification:
1.
				Explanation of Medicare Benefits (EOMB) is not acceptable, and
2. Must be from a Medicare Administrative
				Contractor.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 216 - Dialysis Services › Chapter 1 - Dialysis Services › Rule 23-216-1.2 - Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid covers:
1. Hemodialysis,
2. Peritoneal dialysis,
3. Continuous Ambulatory Peritoneal Dialysis
				(CAPD), and
4. Continuous Cyclic
				Peritoneal Dialysis (CCPD).
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 216 - Dialysis Services › Chapter 1 - Dialysis Services › Rule 23-216-1.3 - Bundled ESRD PPS /Definition of Units

Current through June 25, 2024
Effective July 1, 2021, the Division of Medicaid reimburses
				  freestanding and hospital-based ESRD facilities the bundled ESRD PPS rate
				  effective as of January 1, 2021 for all resources used in providing outpatient
				  dialysis services, including supplies and equipment used to administer dialysis
				  in the ESRD facility or at a beneficiary's home, drugs, biologicals, laboratory
				  tests and support services.
1. The
				facility must furnish all necessary services, equipment, and
				supplies.
2. The appropriate
				revenue codes must be billed for the ESRD PPS rate.
3. Dialysis services are not reimbursed if
				there are no corresponding treatment notes.
The Division of Medicaid covers three (3) units of
				  hemodialysis per a seven (7) day week.
1. Hemodialysis is typically furnished three
				(3) times per week in treatment sessions lasting four (4) to five (5)
				hours.
2. One (1) unit is equal to
				one (1) treatment session.
The Division of Medicaid covers one (1) unit for each day, up
				  to thirty-one (31) days, per month for home hemodialysis, peritoneal dialysis,
				  Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling
				  Peritoneal Dialysis (CCPD). The Division of Medicaid defines one (1) unit as
				  one (1) twenty-four (24) hour day.
Medical documentation substantiating the medical necessity
				  for additional units is required.
42 CFR 494;
				  Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 216 - Dialysis Services › Chapter 1 - Dialysis Services › Rule 23-216-1.4 - Professional Services

Current through June 25, 2024
A. The Division of
				Medicaid covers related physician services for ESRD billed with the
appropriate procedure codes which are excluded from the ESRD
				  PPS rate.
1. The physician or
				qualified health care professional must provide one (1) face-to-face visit with
				the beneficiary monthly.
2. The
				medical record must contain the physician or qualified health care
				professional's documentation substantiating the medical necessity for
				additional face-to-face visits.
3.
				Documentation must be legibly written, signed and dated during the face-to-face
				visit.
4. Documentation by the
				interdisciplinary team cannot substantiate the medical necessity of the
				physician or qualified health care professional's face-to-face visit.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 216 - Dialysis Services › Chapter 1 - Dialysis Services › Rule 23-216-1.5 - Documentation Requirements

Current through June 25, 2024
A. Dialysis
				providers must maintain auditable records that substantiate the dialysis
				services provided.
B. The physician
				or qualified healthcare professional's documentation in the medical record must
				include, but is not limited to, the following:
1. Dates of service,
2. Monthly face-to-face evaluation of the
				beneficiary's current health status, medical condition, provider findings and
				appropriateness of the treatment plan,
3. Mode of dialysis and treatment
				plan,
4. All treatments,
				medications, biologicals, lab tests and other studies both included and
				excluded in the ESRD PPS rate, and
5. A legible signature of the physician or
				qualified healthcare professional with documented credentials to support the
				service rendered and date of entry.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 216 - Dialysis Services › Chapter 1 - Dialysis Services › Rule 23-216-1.6 - Immunizations

Current through June 25, 2024
A. The Division of Medicaid reimburses
				dialysis facilities for influenza and pneumonia vaccines when provided by and
				administered by the dialysis facility to beneficiaries receiving dialysis
				services.
B. Influenza and
				pneumonia vaccines are excluded from the ESRD PPS rate.
Miss. Code Ann. §
										43-13-121.