Mississippi Administrative Code › Title 20 - Labor › Part 2 - Mississippi Workers' Compensation Medical Fee Schedule › AUTHORIZATION/PRE-CERTIFICATION RULES › Section 20-2-III - STANDARDS

Current through June 25, 2024
Payers, providers and their utilization review organizations
				  or programs or agents are required to meet the following standards:
A. The payer's utilization reviewer or agent
				must comply with the licensing and certification requirements of MCA §
									41-83-1 et
				seq. (Rev. 2005), as amended, and any regulations adopted pursuant thereto by
				the State Department of Health or the State Board of Medical Licensure, and
				shall have utilization review personnel, agents or representatives who are
				properly qualified, trained, supervised, and supported by explicit clinical
				review criteria and review procedures. In no event shall proposed treatment or
				services be denied except in accordance with the express provisions stated
				elsewhere in these Rules and in accordance with MCA §41-83- 31 (Rev.
				2009).
B. The first level review
				is performed if the claims adjuster or manager has not already approved the
				treatment in question, and is performed by individuals who are health care
				professionals, who possess a current and valid professional license, and who
				have been trained in the principles and procedures of utilization review.
C. The first level reviewers are
				required to be supported by a doctor of medicine who has an unrestricted
				license to practice medicine, and in cases where treatment is being denied or
				withheld by a utilization reviewer, this determination must be supported in
				writing by a physician licensed in Mississippi and trained in the relevant
				specialty or sub-specialty, as previously set forth in these Rules.
D. The second and third level review is
				performed by clinical peers who hold a current, unrestricted Mississippi
				license to practice in the same or like specialty as the treating physician
				whose recommendation is under review, and are oriented in the principles and
				procedures of utilization review. The second level review shall be conducted
				for all cases where a clinical determination to certify has not already been
				made by the payer or payer's agent, and the determination of medical necessity
				cannot be made by first level clinical reviewers. Second and third level
				clinical reviewers shall be available within one (1) business day by telephone
				or other electronic means to discuss the determination with the attending
				physicians or other ordering providers. In the event more information is
				required before a determination can be rendered by a second or third level
				reviewer, the attending/ordering provider must be notified immediately of the
				delay and given a specific time frame for determination, and a specific
				explanation of the additional information needed. A requesting provider shall
				not be required to participate in further discussions where the payer or its
				agents have unilaterally scheduled such a conference. Further, a request for
				treatment or service may not be denied solely on grounds the requesting
				provider fails to participate in a conference which has been unilaterally
				scheduled by the payer or their agent. Follow-up conferences must be arranged
				by joint agreement.
E. The payer's
				utilization reviewer shall maintain all licensing applications, certificates,
				and other supporting information, including any and all reports, data, studies,
				etc., along with written policies and procedures for the effective management
				of its authorization/pre-certification activities, which shall be made
				available to the provider, or the Commission, upon request.
F. The payer maintains the responsibility for
				the oversight of the delegated functions if the payer delegates
				authorization/pre-certification responsibility to a vendor. The vendor or
				organization to which the function is being delegated must be currently
				certified by the Mississippi Board of Health, Division of Licensure and
				Certification to perform utilization management in the State of Mississippi. A
				copy of the license or certification held by the utilization review agent shall
				be furnished to the provider, or to the Commission, upon request. The payer who
				has another entity perform authorization/pre-certification functions or
				activities on its behalf maintains full responsibility for compliance with the
				rules.
G. The payer's utilization
				reviewer shall maintain a telephone review service that provides access to its
				review staff at a toll free number from at least 9:00 a.m. to 5:00 p.m. CT each
				normal business day. There should be an established procedure for receiving or
				redirecting calls after hours or receiving faxed or electronic requests.
				Reviews should be conducted during hospitals' and health professionals'
				reasonable and normal business hours.
H. The payer's utilization reviewer shall
				collect only the information necessary to certify the admission procedure or
				treatment, length of stay, frequency, and duration of services. The utilization
				reviewer should have a process to share all clinical and demographic
				information on individual workers among its various clinical and administrative
				departments to avoid duplicate requests to providers.
I. Providers must submit a request to the
				payer using the MWCC Request for Authorization/Pre-certification. (A copy of
				this form is provided in the forms section of this fee schedule.)