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 3 - DEFINITIONS

Current through June 25, 2024
1. Appeal: A formal request to reconsider a
				  determination not to certify an admission, extension of stay, or other medical
				  service.
2. Attending Physician:
				  The physician with primary responsibility for the care provided to a patient in
				  a hospital or other health care facility.
3. Certificate: A certificate of registration
				  granted by the Mississippi Department of Health to a private review agent, and
				  is not transferable.
4.
				  Certification: A determination by a utilization review organization that an
				  admission, extension of stay, or other medical service has been reviewed and
				  based on the information provided, qualifies as medically necessary and
				  appropriate under the medical review requirements of the applicable health
				  benefit plan.
5. Certification
				  Number: The number assigned to each certified private review agent. This number
				  is not transferable.
6. Certified
				  Private Review Agent: A private review agent who meets all the criteria for
				  certification as set forth in these rules and regulations, has paid all current
				  fees, and has been assigned a certification number.
7. Concurrent Review: Utilization review
				  conducted during a patient's hospital stay or course of treatment.
8. Consulting Physician: A Medical Doctor,
				  Doctor of Osteopathy, Dentist, Psychologist, Podiatrist or Chiropractor who
				  possess the degree of skill ordinarily possessed and used by members of his or
				  her profession in good standing, and actively engaged in the same type of
				  practice and relevant specialty. The medical and osteopathy specialist shall be
				  certified by the Boards within the American Board of Medical Specialists or the
				  American Board of Osteopathy.
9.
				  Department: The Mississippi Department of Health.
10. Director: The Director of the Division of
				  Health Facilities Licensure and Certification of the Mississippi Department of
				  Health.
11. Enrollee: The
				  individual who has elected to contract for, or participate in, a health benefit
				  plan for their self and/or their dependents.
12. Expedited Appeal: A request for
				  additional review of a utilization review organization's determination not to
				  certify an admission, extension of stay, or other medical service. An expedited
				  appeal request may be called a reconsideration request by some utilization
				  review organizations.
13. Hospital:
				  An institution which is primarily engaged in providing to inpatients, by or
				  under the supervision of physicians, diagnostic services and therapeutic
				  services for medical diagnosis, treatment and care of injured, disabled or sick
				  persons, or rehabilitation services for the rehabilitation of injured, disabled
				  or sick persons, and also, means a place devoted primarily to the maintenance
				  and operation of facilities for the diagnosis, treatment and illness, disease,
				  injury or deformity, or a place devoted primarily to providing obstetrical or
				  other medical, surgical or nursing care of individuals, whether or not any such
				  place be organized or operated for profit and whether any such place be
				  publicly or privately owned. The term "Hospital" does not include convalescent
				  or boarding homes, children's homes, homes for the aged or other like
				  establishments where room and board only are provided, nor does it include
				  offices or clinics where patients are not regularly kept as bed
				  patients.
14. Patient: The intended
				  recipient of the proposed health care, his/her representative, and/or the
				  enrollee.
15. Physician Advisor: A
				  physician representing the claim administrator/utilization review organization
				  who provides advice on whether to certify an admission, extension of stay, or
				  other medical service as being medically necessary and appropriate.
16. Private Review Agent: A non-hospital
				  affiliated person or entity performing utilization review on behalf of:
a. An employer or employees in the State of
				  Mississippi; or
b. A third party
				  that provides or administers hospital and medical benefits to citizens of this
				  state, including: a health maintenance organization issued a certificate of
				  authority under and by virtue of the laws of the State of Mississippi, or a
				  health insurer, nonprofit health service plan, health insurance service
				  organization, or preferred provider organization or other entity offering
				  health insurance policies, contracts or benefits in this state.