Mississippi Administrative Code › Title 15 - Mississippi Department of Health › Part 16 - Health Facilities › Subpart 1 - Health Facilities Licensure and Certification › Chapter 82 - MINIMUM STANDARDS FOR UTILIZATION REVIEW AGENTS › Subchapter 7 - UTILIZATION REVIEW STANDARDS › Rule 15-16-1-82.7.5 - Procedures For Review Determination

Current through June 25, 2024
1. Each private
					 review agent shall have written procedures to assure that reviews are conducted
					 in a timely manner.
2. Each private
					 review agent shall make certification determinations within two working days of
					 receipt of the necessary information on a proposed admission or service
					 requiring a review determination. Collection of the necessary information may
					 necessitate a discussion with the attending physician or, based on the
					 requirements of the health benefit plan, may involve a completed second opinion
					 review.
3. A private review agent
					 may review ongoing inpatient stays, but shall not routinely conduct daily
					 review on all such stays. The frequency of the review for extension of the
					 initial determination should vary based on the severity or complexity of the
					 patient's condition or on necessary treatment and discharge planning activity.
					 Routine concurrent review generally should not be necessary earlier than 24
					 hours prior to the lapse of the certified length of stay.
4. Each private review agent shall have in
					 place written procedures for providing notification of its determination
					 regarding certification, recertification, or extensions of previously
					 authorized length of stay in accordance with the following:
5. When an initial determination is made to
					 certify, notification shall be provided promptly either by telephone or in
					 writing, to the attending physician. The notification shall be transmitted in
					 writing to the hospital and attending physician, as well as to the enrollee or
					 patient, within two working days.
6. A determination to certify resulting from
					 concurrent review shall be transmitted to the attending physician by telephone
					 or in writing within one working day of receipt of all information necessary to
					 complete the review process or prior to the end of the current certified
					 period.
7. If a private review
					 agent transmits written confirmation of certification for continued
					 hospitalization, that notification shall include the number of extended days,
					 the new total number of days approved, and the date of admission.
8. When a determination is made not to
					 certify a hospital or surgery facility admission or extension of a hospital
					 stay or other service requiring review determination, the attending physician
					 shall be notified by telephone within one working day and a written
					 notification should be sent within one working day to the hospital, attending
					 physician and the enrollee or patient. The written notification shall include
					 the principal reason(s) for the determination and the way to initiate an appeal
					 of the determination if the enrollee, patient, or their representative so
					 chooses. Reasons for a determination not to certify shall include, among other
					 things, the lack of adequate information to certify after a reasonable attempt
					 has been made to contact the attending physician.
Miss. Code Ann.
						§41.83.1