reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 1 - Telehealth Services › Rule 23-225-1.4 - Non-Covered Services

Current through June 25, 2024
The Division of Medicaid does not:
A. Cover a telehealth service if that same
				service is not covered in an in-person setting.
B. Cover a separate reimbursement for the
				installation or maintenance of telehealth hardware, software and/or equipment,
				videotapes, and transmissions.
C.
				Cover early and periodic screening, diagnosis, and treatment (EPSDT) well child
				visits through telehealth.
D. Cover
				physician or other practitioner visits through telehealth for non-established
				beneficiaries.
E. Consider the
				following as telehealth services:
1. Telephone
				conversations,
2. Chart
				reviews;
3. Electronic mail
				messages;
4. Facsimile
				transmission;
5. Internet services
				for online medical evaluations, or
6. Communication through social media,
				or
7. Any other communication made
				in the course of usual business practices including, but not limited to,
a) Calling in a prescription refill,
				or
b) Performing a quick virtual
				triage.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 1 - Telehealth Services › Rule 23-225-1.5 - Reimbursement

Current through June 25, 2024
A. The Division of Medicaid reimburses the
				provider at the originating site the Mississippi Medicaid telehealth
				originating site facility fee for telehealth services per completed
				transmission, in addition to a separately identifiable covered service if
				performed.
1. The following providers are
				eligible to receive the originating site facility fee for telehealth services
				per transmission:
a) The office of a physician
				or practitioner,
b) An outpatient
				hospital, including a Critical Access Hospital (CAH),
c) A Rural Health Clinic (RHC),
d) A Federally Qualified Health Center
				(FQHC),
e) A Community Mental
				Health/Private Mental Health Center,
f) A Therapeutic Group Home,
g) An Indian Health Service Clinic,
h) A School-Based Clinic, or
i) School which employs a nurse.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 1 - Telehealth Services › Rule 23-225-1.6 - Documentation

Current through June 25, 2024
The provider must document the same information as for a
				  comparable in-person service and be maintained at both the originating and
				  distant site of the telehealth services provided including, but not limited
				  to:
A. Signed consent for treatment
				using telehealth,
B. Medically
				appropriate reason telehealth was utilized to provide services,
C. Beneficiary's presenting diagnosis and
				symptoms,
D. Specific name/type of
				all diagnostic studies and results/findings of the studies, and
E. Plan of Care.
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 1 - Telehealth Services › Rule 23-225-1.7 - Procedures during States of Emergency

Current through June 25, 2024
The Mississippi Division of Medicaid will allow additional
				  coverage of telehealth services during a state of emergency as declared by
				  either the Governor of Mississippi or the President of the United States.
				  Details of enhanced services include the following that will terminate at the
				  discretion of the Mississippi Division of Medicaid:
A. A beneficiary may seek treatment utilizing
				telehealth services from an originating site not listed in the Mississippi
				Medicaid State Plan regarding Telehealth (SPA 3.1-A Introductory Pages 1 and
				2). These emergency exceptions include the following:
1. A beneficiary's residence may be an
				originating site without prior approval by the Division of Medicaid.
2. Health care facilities not listed in the
				State Plan wishing to act as an originating site must first be granted approval
				by the Division of Medicaid before rendering originating site telehealth
				services.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 2 - Remote Patient Monitoring Services › Rule 23-225-2.1 - Definitions

Current through June 25, 2024
A. The Division of Medicaid defines telemedicine as a method
				  which uses electronic information and communication equipment to supply and
				  support health care when remoteness disconnects patients and links primary care
				  physicians, specialists, providers, and beneficiaries which includes, but is
				  not limited to, telehealth services, remote patient monitoring services,
				  teleradiology services, store-and-forward and continuous glucose monitoring
				  services.
B. The Division of Medicaid defines remote patient monitoring
				  as using digital technologies to collect medical and other forms of health data
				  from individuals in one location and electronically transmit that information
				  securely to healthcare providers in a different location for interpretation and
				  recommendation.
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 2 - Remote Patient Monitoring Services › Rule 23-225-2.2 - General Provider Information

Current through June 25, 2024
A. Providers of
				remote patient monitoring services must comply with all requirements set forth
				in Miss. Admin. Code Part 200, Rule 4.8 for all providers in addition to the
				provider specific requirements below:
1.
				National Provider Identifier (NPI), verification from National Plan and
				Provider Enumeration System (NPPES),
2. Copy of current licensure card or permit,
				and
3. Verification of social
				security number using a social security card, military ID or a notarized
				statement signed by the provider noting the social security number. The name
				noted on the verification must match the name noted on the W-9.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 2 - Remote Patient Monitoring Services › Rule 23-225-2.3 - Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid covers remote patient monitoring of devices when medically necessary,
				ordered by a physician, physician assistant or nurse practitioner which
				includes, but not limited to:
1. Implantable
				pacemakers,
2.
				Defibrillators,
3. Cardiac
				monitors,
4. Loop recorders,
				and
5. External mobile
				cardiovascular telemetry.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 2 - Remote Patient Monitoring Services › Rule 23-225-2.4 - Non-Covered Services

Current through June 25, 2024
The Division of Medicaid does not cover remote patient
				  monitoring for disease management as outlined in Miss. Admin. Code Part 225,
				  Rule 2.3.B. for a beneficiary who is a resident of an institution that meets
				  the basic definition of a hospital or long-term care
				  facility.
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 2 - Remote Patient Monitoring Services › Rule 23-225-2.5 - Reimbursement

Current through June 25, 2024
A. The Division of Medicaid reimburses for
				remote patient monitoring:
1. Of devices when
				billed with the appropriate code, and
2. For disease management:
a) A daily monitoring rate for days the
				beneficiary's information is reviewed.
b) Only one (1) unit per day is allowed, not
				to exceed thirty-one (31) days per month.
c) An initial visit to install the equipment
				and train the beneficiary may be billed as a set-up visit.
d) Only one set-up is allowed per episode
				even if monitoring parameters are added after the initial set-up and
				installation.
e) Only one (1)
				daily rate will be reimbursed regardless of the number of diseases/chronic
				conditions being monitored.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 2 - Remote Patient Monitoring Services › Rule 23-225-2.6 - Documentation

Current through June 25, 2024
The provider must document the remote patient monitoring
				  service the same as for a comparable in person service which includes, but is
				  not limited to:
A. The monitoring
				equipment meets all of the following requirements:
1. Capable of monitoring any data parameters
				included in the plan of care,
2.
				Food and Drug Administration (FDA) Class II hospital-grade medical device, and
3. Capable of accurately measuring
				and transmitting beneficiary glucose and/or blood pressure data.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 3 - Teleradiology Services › Rule 23-225-3.1 - Definitions

Current through June 25, 2024
The Division of Medicaid defines telemedicine as a method
				  which uses electronic information and communication equipment to supply and
				  support health care when remoteness disconnects patients and links primary care
				  physicians, specialists, providers, and beneficiaries which includes, but is
				  not limited to, telehealth services remote patient monitoring services,
				  teleradiology services, store-and-forward and continuous glucose monitoring
				  services.
A.The Division of Medicaid defines
				  store-and-forward as telecommunication technology for the transfer of medical
				  data from one (1) site to another through the use of a camera or similar device
				  that records or stores an image which is transmitted or forwarded via
				  telecommunication to another site for teleconsultation and includes, but is not
				  limited to, teleradiology services.
B.The Division of Medicaid defines a:
1.Teleradiology service as the electronic
				  transmission of radiological images, known as store-and-forward images, from
				  one (1) location to another for the purposes of interpretation.
2.Consulting provider as a licensed physician
				  who interprets the radiological image, at the distant site and who must be
				  licensed in the state within the United States in which he/she
				  practices.
3.Distant site, also
				  referred to as a hub site, as the location of the teleradiology consulting
				  provider.
4.Referring provider as a
				  licensed physician, physician assistant, or nurse practitioner who orders the
				  radiological service and who must be licensed in the state within the United
				  States in which he/she practices.
5.Originating site, also referred to as the
				  spoke site, as the location where the beneficiary is receiving the
				  teleradiology service.
A. Store-and-forward as telecommunication technology for
					 the transfer of medical data from one (1) site to another through the use of a
					 camera or similar device that records or stores an image which is transmitted
					 or forwarded via telecommunication to another site for teleconsultation and
					 includes, but is not limited to, teleradiology.
7.The transmission cost
					 as the cost of the line charge incurred during the time of the transmission of
					 a telehealth service.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 3 - Teleradiology Services › Rule 23-225-3.2 - General Provider Information

Current through June 25, 2024
A. Providers of
				teleradiology services must comply with all requirements set forth in Miss.
				Admin. Code Part 200, Rule 4.8 for all providers in addition to the provider
				specific requirements below:
1. National
				Provider Identifier (NPI), verification from National Plan and Provider
				Enumeration System (NPPES),
2.
				Copy of current licensure card or permit, and
3. Verification of social security number
				using a social security card, military ID or a notarized statement signed by
				the provider noting the social security number. The name noted on the
				verification must match the name noted on the W-9.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 3 - Teleradiology Services › Rule 23-225-3.3 - Covered Services

Current through June 25, 2024
The Division of Medicaid covers:
A. One (1) technical and one (1) professional
				component for each teleradiology procedure only for providers enrolled as a
				Mississippi Medicaid provider and when there are no geographically local
				radiologist providers to interpret the images.
B. The technical component of the
				radiological service is covered at the originating site.
C. The professional component of the
				radiological service is covered at the distant site.
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 3 - Teleradiology Services › Rule 23-225-3.4 - Non-Covered Services

Current through June 25, 2024
The Division of Medicaid does not cover:
A. The transmission cost or any other
				associated cost of teleradiology,
B. Both the technical and professional
				component of teleradiology services for one (1) provider, or
C. One (1) provider billing for services
				performed by another provider.
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 3 - Teleradiology Services › Rule 23-225-3.5 - Reimbursement

Current through June 25, 2024
A. The Division of Medicaid reimburses for:
1. The technical component of the
				radiological service at the originating site for only providers enrolled as a
				Mississippi Medicaid provider.
2.
				The professional component of the radiological service at the distant site only
				for providers enrolled as a Mississippi Medicaid provider.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 3 - Teleradiology Services › Rule 23-225-3.6 - Documentation

Current through June 25, 2024
A. Teleradiology documentation must include,
				but not limited to:
1. At the originating
				site:
a) The reason teleradiology was
				utilized to deliver the service including there was no local radiologists to
				interpret the images,
b) Date(s)
				of service,
c) Beneficiary
				demographic information,
d) Signed
				consent for treatment, if applicable,
e) Medical history,
f) Beneficiary's presenting complaint,
g) Diagnosis, and
h) Specific name/type of all diagnostic
				studies and results/findings of the studies.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 4 - Continuous Glucose Monitoring Services › Rule 23-225-4.1 - Definitions

Current through June 25, 2024
A.The Division of Medicaid defines
				telemedicine as a method which uses electronic information and communication
				equipment to supply and support health care when remoteness disconnects
				patients and links primary care physicians, specialists, providers, and
				beneficiaries which includes, but is not limited to, telehealth services remote
				patient monitoring services, teleradiology services, store-and-forward, and
				continuous glucose monitoring services.
B.The Division of Medicaid defines a
				continuous glucose monitoring service as:
1.
				The download, retrospective review and interpretation of blood
				glucose values by a physician, physician's assistant or nurse practitioner when
				captured for more than seventy-two (72) hours on a continuous glucose monitor
				system, and
2.Adjunct monitoring,
				not an alternative, to traditional self-monitoring of blood glucose levels,
				supplying additional information on glucose trends that are not available from
				self-monitoring.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 4 - Continuous Glucose Monitoring Services › Rule 23-225-4.2 - General Provider Information

Current through June 25, 2024
A. Providers of
				continuous glucose monitoring services must comply with all requirements set
				forth in Miss. Admin. Code Part 200, Rule 4.8 for all providers in addition to
				the provider specific requirements below:
1.
				National Provider Identifier (NPI), verification from National Plan and
				Provider Enumeration System (NPPES),
2. Copy of current licensure card or permit,
				and
3. Verification of social
				security number using a social security card, military ID or a notarized
				statement signed by the provider noting the social security number. The name
				noted on the verification must match the name noted on the W-9.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 4 - Continuous Glucose Monitoring Services › Rule 23-225-4.3 - Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid covers:
1. A continuous glucose
				monitoring (CGM) service when medically necessary, prior authorized by the
				UM/QIO, Division of Medicaid or designee, ordered by the physician who is
				actively managing the beneficiary's diabetes and the beneficiary meets all of
				the following criteria:
a) Has an established
				diagnosis of type I or type II diabetes mellitus that is poorly controlled as
				defined below:
1) Unexplained hypoglycemic
				episodes,
2) Nocturnal hypoglycemic
				episode(s),
3) Hypoglycemic
				unawareness and/or frequent hypoglycemic episodes leading to impairments in
				activities of daily living,
4)
				Suspected postprandial hyperglycemia,
5) Recurrent diabetic ketoacidosis,
				or
6) Unable to achieve optimum
				glycemic control as defined by the most current version of the American
				Diabetes Association (ADA).
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 4 - Continuous Glucose Monitoring Services › Rule 23-225-4.4 - Non-Covered Services

Current through June 25, 2024
The Division of Medicaid does not cover continuous glucose
				  monitoring for:
A. Non-diagnostic or
				personal use at home, or
B.
				Beneficiaries with type II diabetes mellitus.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 4 - Continuous Glucose Monitoring Services › Rule 23-225-4.5 - Reimbursement

Current through June 25, 2024
A. The Division of Medicaid reimburses for:
1. One (1) retrospective review and
				interpretation of blood glucose values per month, and
2. A one (1) time device hook-up which
				includes beneficiary education.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 225 - Telemedicine › Chapter 4 - Continuous Glucose Monitoring Services › Rule 23-225-4.6 - Documentation

Current through June 25, 2024
Continuous glucose monitoring (CGM) service documentation
				  must include, but is not limited to:
A.
				The beneficiary and/or care giver is capable of operating the continuous
				glucose monitoring system,
B. The
				beneficiary:
1. Has an established diagnosis
				of type I or type II diabetes mellitus that is poorly controlled as defined in
				Miss. Admin. Code Part 225, Rule
				4.3.A.1.a),
2. Requires three (3) insulin injections per
				day, or use of an insulin pump, for maintenance of blood glucose
				control,
3. Requires regular
				self-monitoring of at least four (4) times a day,
4. Requires frequent adjustment to insulin
				treatment regimen based on blood glucose testing results,
5. Had an in-person visit with the ordering
				physician within six (6) months prior to ordering to evaluate their diabetes
				control and determined that criteria (1-4) above are met,
6. Has an in-person visit every six (6)
				months following the prescription of the CGM to assess adherence to the CGM
				regimen and diabetes treatment plan.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 1 - Appeals Overview › Rule 23-300-1.1 - Authority to Conduct Appeals

Current through June 25, 2024
Title 23, Part 300 of the Mississippi Division of Medicaid's
				  Administrative Code establishes procedures applicable to Appeals and Fair
				  Hearings conducted by the Mississippi Division of Medicaid pursuant to 42
				  C.F.R. Part 431 Subpart E, 42 C.F.R. Part 438 Subpart F, 42 C.F.R. Part 455
				  Subpart E, Miss. Code Ann. §§
									43-13-116,
				  43-13-117, and
				  43-13-121.
42 C.F.R. Part
				  431 Subpart E; 42 C.F.R. Part 438 Subpart F; 42 C.F.R. Part 455 Subpart E;
				  Miss. Code Ann. §§
										43-13-116,
				  43-13-117,
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 1 - Appeals Overview › Rule 23-300-1.2 - Categories of Appeals

Current through June 25, 2024
A. The Division of Medicaid provides an
				appeal process for applicants, beneficiaries, and providers.
B. Appeals for Fee-for-Service (FFS)
				Applicants, Beneficiaries, and Providers
1.
				An applicant or beneficiary, or an applicant/beneficiary's representative
				wishing to appeal a Reconsideration decision originating from FFS Medicaid must
				file the appeal directly with the Division of Medicaid, following rules and
				procedures stated in Part 300, Chapter 2.
2. A provider wishing to appeal a Final
				Agency Action originating from FFS Medicaid must file the appeal directly with
				the Division of Medicaid, following rules and procedures stated in Part 300,
				Chapter 3.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.1 - Authority for Applicant and Beneficiary Appeals

Current through June 25, 2024
The Mississippi Medicaid Law governing the administration of
				  medical assistance makes provision under Section
				  43-13-116 of the Mississippi Code
				  of 1972, as amended, for fair and impartial hearings in full implementation of
				  the Federal statutory and regulatory requirements. Any person whose claim for
				  assistance is denied or not acted upon promptly may request a hearing from the
				  Division of Medicaid, if the Division of Medicaid is the determining
				  agency.
42 C.F.R. Part
				  431 Subpart E; Miss. Code Ann. §§
										43-13-116,
				  43-13-117,
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.2 - Definitions

Current through June 25, 2024
The Division of Medicaid defines:
A. Case Record as all documents relevant to
				the administration of an appeal, including but not limited to all
				correspondence, applications, medical records and decisions, and past
				appeals.
B. Course of Treatment as
				a planned program of one or more services or supplies.
C. Grievance as an expression of
				dissatisfaction submitted orally or in writing about any matter, including but
				not limited to the quality of services provided, rudeness from a Division of
				Medicaid employee, unfair treatment, or failure to respect the applicant or
				beneficiary's rights.
D. Local
				Hearing or Reconsideration as a hearing held at the Division of Medicaid
				Regional Office from which the decision the applicant or beneficiary wishes to
				appeal was generated.
E. State
				Hearing or Fair Hearing as an orderly, but informal meeting in which an
				applicant or beneficiary or his/her representative is afforded an opportunity
				to address an impartial hearing officer for the purpose of presenting oral
				testimony and/or evidence of the individual's entitlement to medical assistance
				and services.
1. The applicant or beneficiary
				has the right of confrontation and cross-examination.
2. A fair hearing is a de novo hearing which
				means the determination process starts over from the beginning. A new
				determination of the applicant or beneficiary's eligibility is made based on
				all the evidence that can be secured, without regard to whether the evidence
				was available at the time the regional office took action. Thus, the process is
				not essentially different from a determination of eligibility.
3. This hearing is conducted by the Division
				of Medicaid's Central Office.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.3 - Appeal Rights of Applicants and Beneficiaries

Current through June 25, 2024
A. The Division of Medicaid provides an
				opportunity to contest any adverse decisions through an appeal and fair hearing
				process, and notifies applicants, beneficiaries and/or their legal
				representatives of their Medicaid appeal rights. The following categories have
				appeal processes through the Division of Medicaid:
1. Fee-for-service (FFS)
				beneficiaries,
2. Beneficiaries
				enrolled in a coordinated care organization (CCO),
3. Beneficiaries enrolled in a Medicaid
				waiver,
4. Beneficiaries who are
				subject to a proposed transfer or discharge from a long-term care facility or
				nursing facility,
5. Individuals
				who are adversely affected by the pre-admission screening or the annual
				resident review, and
6. Any other
				Medicaid applicants or beneficiaries not enumerated herein.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.4 - Types of Hearings

Current through June 25, 2024
A. The applicant or beneficiary, or their
				representative may request to present an appeal through a local hearing, a
				state hearing, or both.
B. There
				are two instances in which a local hearing is not permitted, and the applicant
				or beneficiary must request relief directly through a state hearing. These are:
1. A disability or blindness denial, or
				termination, or
2. A level of care
				denial or termination for a Disabled Child Living at Home.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.5 - Applicant Appeals

Current through June 25, 2024
Appeals regarding eligibility must be filed with the agency
				  through which the applicant/beneficiary first applied. Agencies include:
A. Mississippi Division of Medicaid,
1. The Mississippi Division of Medicaid is
				responsible for making eligibility determinations for the following groups:
a) Families,
b) Children,
c) Pregnant Women, and
d) Aged, blind and disabled individuals who
				do not qualify for Social Security Income.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.6 - Beneficiary Appeals

Current through June 25, 2024
A. The Division of Medicaid provides
				beneficiaries the opportunity to request a fair hearing in order to appeal
				decisions of:
1. Eligibility,
2. Denial,
3. Termination,
4. Suspension, or
5. Reduction of Medicaid covered
				services.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.7 - All Hearing Requests

Current through June 25, 2024
A. All hearing requests may initially be
				written, oral, or made in-person at a regional office.
B. Written Hearing Requests
1. A simple statement requesting a hearing
				that is signed by the applicant/beneficiary or the applicant/beneficiary's
				legal representative is sufficient.
2. The written request may be mailed to the
				regional office or central office. If the letter does not specify the type of
				hearing desired, a Medicaid specialist will contact the person making the
				request to determine whether a local or a state hearing is being requested. If
				contact cannot be made within three (3) days of receipt of the hearing request,
				the regional office will assume a local hearing is requested and schedule
				accordingly.
3. If the hearing
				involves an issue that requires that a state hearing be held or if a state
				hearing is requested, the request will be forwarded to the Office of
				Administrative Appeals.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.8 - Time Limit For Filing A Hearing Request

Current through June 25, 2024
A. The applicant or beneficiary has thirty
				(30) days from the postmark date of the appropriate notice to request either a
				local or state hearing. This thirty (30) day filing period may be extended if
				the applicant or beneficiary can show good cause, as determined by the Division
				of Medicaid, for not filing within thirty (30) days.
B. When good cause is shown, a late hearing
				request may be accepted, provided the facts in the case remain the
				same.
C. If good cause for filing a
				request beyond thirty (30) days does not exist, a hearing request will not be
				accepted.
D. If the applicant or
				beneficiary wishes to have his/her eligibility reconsidered after this period,
				s/he may reapply.
42 C.F.R. Part
				  431 Subpart E; Miss. Code Ann. §§
										43-13-116,
				  43-13-117,
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.9 - Timeframe for Holding Local or State Hearings

Current through June 25, 2024
The Division of Medicaid must take final administrative
				  action on a hearing, whether state and/or local, within ninety (90) days of the
				  date of the initial request for a hearing.
42 C.F.R. Part
				  431 Subpart E; Miss. Code Ann. §§
										43-13-116,
				  43-13-117, and
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.10 - Scheduling the Hearing

Current through June 25, 2024
A. When a local hearing is requested, the
				regional office will notify the applicant/beneficiary or representative in
				writing of the time and date of the local hearing.
B. When a state hearing is requested, the
				hearing officer assigned to the case will notify the applicant/beneficiary or
				representative in writing of the time and date of the state hearing.
C. The notice scheduling the time and date of
				a state or local hearing must be mailed to the applicant or beneficiary at
				least five (5) days before the day the hearing is scheduled. A hearing pamphlet
				will be included with the letter scheduling either a local or state
				hearing.
42 C.F.R. Part
				  431 Subpart E; Miss. Code Ann. §§
										43-13-116,
				  43-13-117,
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.11 - Attendance at the Hearing

Current through June 25, 2024
A. A state or local hearing is not open to
				the public. Persons attending the hearing will attend for the purpose of:
1. Giving information on behalf of the
				applicant or beneficiary,
2.
				Rendering the applicant or beneficiary assistance in some other way,
				or
3. To represent the Division of
				Medicaid.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.12 - Withdrawn or Abandoned Hearings

Current through June 25, 2024
A. Withdrawal of a request for hearing must
				be in writing and submitted by:
1. The
				applicant/beneficiary, or
2. The
				applicant/beneficiary's representative, and
3. Bear the applicant/beneficiary's signature
				or the representative's signature.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.13 - Rights of the Applicant/Beneficiary During the Hearing Process

Current through June 25, 2024
The applicant/beneficiary or his/her representative has the
				  following rights in connection with a local or state hearing:
A. The right to examine the contents of the
				case record at a reasonable time before the date of the hearing and during the
				hearing. In cases of eligibility appeals, the beneficiary will be mailed a copy
				of the case file by the Division,
B. The right to have legal representation at
				the hearing, and to bring witnesses,
C. The right to produce documentary evidence
				and establish all pertinent facts and circumstances concerning eligibility,
				and
D. The right to present an
				argument without undue interference and to question or refute testimony or
				evidence, including an opportunity to confront and cross-examine adverse
				witnesses.
42 C.F.R. Part
				  431 Subpart E, Miss. Code Ann. §§
										43-13-116,
				  43-13-117,
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.14 - Local Hearing Requests

Current through June 25, 2024
A. A local hearing request will ordinarily be
				filed in the regional office responsible for the adverse decision or delay in
				action.
B. An applicant or
				beneficiary who has moved to another regional office's jurisdiction at the time
				the appeal is made may submit an appeal in the regional office serving the
				applicant or beneficiary's current county of residence. The hearing officer may
				request the participation of staff in the regional office where the action was
				originally taken if necessary or advisable.
42 C.F.R. Part
				  431 Subpart E; Miss. Code Ann. §§
										43-13-116,
				  43-13-117,
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.15 - Local Hearing Procedure

Current through June 25, 2024
A. The purpose of a local hearing is to
				provide an informal proceeding to allow the applicant/beneficiary or
				representative to:
1. Present new or
				additional information;
2. Question
				the action taken on the applicant/beneficiary's case, and
3. Hear an explanation of eligibility
				requirements as they pertain to the applicant/beneficiary's
				situation.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.16 - State Hearing Requests After Adverse Local Decision

Current through June 25, 2024
A. The applicant or beneficiary has the right
				to appeal a local hearing decision by requesting a state hearing; however, the
				state hearing request must be made within fifteen (15) days of the postmark
				date of the local hearing decision. This means the state hearing request must
				be received by the regional office or state office on or before the fifteenth
				(15th) day after the local hearing notice is mailed.
B. If benefits have been continued pending
				the local hearing decision, then benefits will continue throughout the fifteen
				(15) day Advance Notice Period, when the local hearing decision is
				adverse.
C. If a state hearing is
				requested timely within the fifteen (15) day period, then benefits will
				continue pending the outcome of the state hearing. State hearings requested
				after the fifteen (15) day Advance Notice Period for the local hearing will not
				be accepted unless the thirty (30) day period for filing a hearing request has
				not expired because the local hearing was held early in the thirty (30) day
				period and there is time remaining.
42 C.F.R. Part
				  431 Subpart E; Miss. Code Ann. §§
										43-13-116,
				  43-13-117,
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.17 - State Hearing Requests for Appeals that Must Originate as a State Hearing

Current through June 25, 2024
A. Disability or Blindness Denials.
1. An appeal related to a disability or
				blindness denial must be resolved through a state hearing. Procedures for
				filing a state hearing appeal are detailed in Rules
				2.5 through
				2.8 of this chapter and should be
				followed.
2. After the state
				hearing, the hearing officer will forward all medical information to the
				Disability Determination Service (DDS) for reconsideration. A review team
				consisting of medical staff who were not involved in any way with the original
				decision will review the medical information and hearing transcript and give a
				decision on the disability or blindness factor.
3. The DDS decision is final and binding on
				the Division of Medicaid.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.18 - State Hearing Procedure

Current through June 25, 2024
A. A state hearing is assigned to an
				impartial hearing officer. The hearing officer has not been involved in any way
				with the action or decision prior to being assigned the appeal at the state
				level. The hearing officer:
1. Reviews the
				local office's action;
2. Schedules
				the hearing;
3. Holds the hearing
				and provides the following explanations to those in attendance:
a) The hearing will be recorded, and a copy
				of the recording made available to the applicant/beneficiary upon
				request,
b) The reason for the
				hearing, i.e., the action taken by the regional office which prompted the
				appeal,
c) The
				applicant/beneficiary's rights, and
d) The purpose of the hearing.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.19 - Appeal By Both Members Of A Couple

Current through June 25, 2024
A. One or both members of a couple may file a
				hearing request either jointly or separately when they are denied benefits and
				that denial arises from the same issue.
B. If a joint hearing is held, both members
				of the couple may present evidence at the hearing, and the agency's decision
				will apply to both individuals.
C.
				If both members of the couple file a hearing request, two hearings will be
				registered. The hearings will be conducted on the same day and in the same
				place, either consecutively or jointly, according to the wishes of the couple.
				If they wish for only one of them to attend the joint hearing, that is
				allowed.
42 C.F.R. Part
				  431 Subpart E; Miss. Code Ann. §§
										43-13-116,
				  43-13-117,
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.20 - Group Hearings

Current through June 25, 2024
A. A group hearing can be held for multiple
				applicants or beneficiaries under the following circumstances:
1. The Division of Medicaid may consolidate
				the cases and conduct a single group hearing when the only issue involved is a
				single law or agency rule common to all members of the group.
2. The applicants or beneficiaries may
				request a group hearing when the only issue involved is a single law or agency
				rule common to all members of the group.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.21 - Continuation of Benefits

Current through June 25, 2024
When an applicant/beneficiary or representative requests a
				  hearing within the Advance Notice Period, benefits must be continued or
				  reinstated to the benefit level in effect prior to the planned adverse action,
				  if a timely request is filed.
A. Timely
				Request for Continuation of Benefits.
1. To
				determine if the request for continuation of benefits is timely, the request
				must be received by the regional office within ten (10) days from the notice
				date of the adverse action.
2. Any
				hearing requested or dated after this period will not be accepted as a timely
				request for continuation of benefits.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 2 - Fee-for-Service Applicant and Beneficiary Appeals › Rule 23-300-2.22 - Appeals for Waiver Beneficiaries Receiving Medicaid Services

Current through June 25, 2024
A. Appeal Procedure for Waivers Administered
				by the Mississippi Department of Rehabilitative Services (MDRS).
1. MDRS administers benefits for the
				following waivers:
a) Independent Living (IL)
				Waiver, and
b) Traumatic Brain
				Injury/Spinal Cord Injury (TBI/SCI) Waiver,
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 3 - Provider Appeals › Rule 23-300-3.1 - Authority for Provider Appeals

Current through June 25, 2024
The Mississippi Division of Medicaid conducts provider
				  hearings for the following reasons:
A.
				The provider is dissatisfied with a Final Agency Action of the Division of
				Medicaid relating to:
1.
				Disallowances,
2. Withholding of
				funds resulting from overpayments,
3. Suspension of payments as a result of an
				audit, review or investigation,
4.
				Termination of a provider agreement as a result of an audit, review or
				investigation,
5. Suspension of
				provider participation as a result of an audit, review or
				investigation,
6. Matters relating
				to payment rates if not previously considered by the Division of Medicaid under
				Public Notice or Public Hearing Procedures,
7. Breach of provider agreement,
8. Provider disqualification,
9. Any other matter that the Division of
				Medicaid deems appropriate in its sole discretion at request of a
				party.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 3 - Provider Appeals › Rule 23-300-3.2 - Definitions

Current through June 25, 2024
The Division of Medicaid defines:
A. Administrative Hearing as a trial-like
				proceeding before the Division of Medicaid at which evidence and testimony may
				be offered.
B. Hearing Officer as
				the presiding officer appointed by the Executive Director or the Executive
				Director's designee to conduct administrative hearings within the guidelines
				stated in this chapter. The Hearing Officer may:
1. Issue subpoenas,
2. Administer oaths,
3. Compel attendance and testimony of
				witnesses,
4. Require the
				production of books, papers, documents, and other evidence required,
5. Take depositions solely for the purposes
				of preserving testimony for the purposes of the administrative
				hearing,
6. Preserve and enforce
				order during the administrative hearing,
7. Call informal, status, or pre-hearing
				conferences, including for the purposes of handling procedural
				matters,
8. Invite stipulations
				between the parties,
9. Do all
				things conformable to law and Medicaid regulations that may be necessary to
				enable the Hearing Officer to effectively discharge the Hearing Officer's
				duties,
10. State that exact costs,
				including but not limited to cost of the Hearing Officer, court reporter,
				attorney's fees, third-party medical review, and any other cost borne by the
				Division in preparing for and conducting the hearing, be assessed to a losing
				provider as part of the recommendation to the Executive Director, and
11. Include the recommendation to the
				Executive Director that the Provider be terminated in cases of egregious
				behavior, such as fraud, waste, and abuse, and that the Provider be reported to
				HHS.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 3 - Provider Appeals › Rule 23-300-3.3 - Pre-Hearing Procedure

Current through June 25, 2024
A. Within thirty (30) calendar days after a
				Final Agency Action has been made, the provider may request a formal
				administrative hearing.
B. Appeal
				requests must:
1. Be written,
2. Explain the facts that support the
				provider's position,
3. Supply
				reasons the provider purports to have complied with the Medicaid
				regulations,
4. Include any
				available documentation supporting the provider's request, and
5. Be timely and proper.
a) Appeals that are not both timely and
				proper are not subject to review and will not be considered by the
				agency.
b) The only exception to
				the timeliness requirement is when a provider can show good cause for late
				filing. The Executive Director of the Division of Medicaid or the Executive
				Director's designee will decide whether the provider has submitted good
				cause.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 3 - Provider Appeals › Rule 23-300-3.4 - Hearing Procedure

Current through June 25, 2024
A. The administrative hearing shall be
				conducted in an informal manner but consistent with courtroom practices and
				procedures.
B. Location of Hearing.
1. The administrative hearing will be held at
				the Division of Medicaid's central office, unless otherwise
				designated.
2. Hearings may be held
				telephonically upon agreement of the parties and if approved by the Hearing
				Officer.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 3 - Provider Appeals › Rule 23-300-3.5 - After the Hearing

Current through June 25, 2024
A. After the hearing has concluded, the
				Hearing Officer shall issue a recommendation with respect to the Final Agency
				Action. The standard of review to be applied by the Hearing Officer is whether
				the Final Agency Action was:
1. Unsupported
				by substantial evidence,
2.
				Arbitrary and capricious,
3. Beyond
				the power of the administrative agency to make, or
4. Violated the complaining party's statutory
				or constitutional rights.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 3 - Provider Appeals › Rule 23-300-3.6 - Post-Decision Relief

Current through June 25, 2024
A. Appeal of a final administrative decision
				must be filed in a court of proper jurisdiction within sixty (60) days from the
				date of notice. The Final Decision will be mailed to the provider by certified
				mail sent to the proper address of the provider on file with the Division of
				Medicaid.
B. Providers filing a
				judicial appeal must post both an appeal bond and a supersedeas bond in the
				court of proper jurisdiction.
C.
				Failure by a provider to either timely file a judicial appeal or secure the
				requisite bonds will serve as ground for dismissal for failure to comply with
				all administrative procedural requirements for appeal.
42 C.F.R. Part
				  455 Subpart E; Miss. Code. Ann. §§
										11-51-31,
				  43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 300 - Appeals › Chapter 3 - Provider Appeals › Rule 23-300-3.7 - Consolidation Requested by a Provider or the Division

Current through June 25, 2024
A. A provider or the Division may request a
				consolidated hearing when two or more matters arise from the same fact pattern
				or involve the same issue of law. The administrative Hearing Officer may grant
				or deny a party's request for consolidation.
B. The Hearing Officer must take into account
				adjudication deadlines for each appeal and may require a requesting party to
				waive the adjudication deadline associated with one or more appeals if
				consolidation otherwise prevents the Hearing Officer from deciding all of the
				appeals at issue within their respective deadlines.
C. Notice of a consolidated hearing will be
				included in the notice of hearing.
D. After a Consolidated Hearing, the Hearing
				Officer may render either:
1. A consolidated
				decision and record, or
2. A
				separate decision and record on each appeal. If a separate decision and record
				on each appeal is made, the Hearing Officer is responsible for making sure that
				any materials, including documents, evidence and testimony, relevant to
				multiple issues are included in each hearing record as appropriate.