reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 216 - Dialysis Services › Chapter 1 - Dialysis Services › Rule 23-216-1.7 - 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 217 - Vision Services › Chapter 1 - General › Rule 23-217-1.1 - Vision Services

Current through June 25, 2024
Vision service is an optional benefit under the state's
				  Medicaid program and financial assistance is provided as follows:
A. Eyeglasses for all Medicaid beneficiaries
				who have had surgery on the eyeball or ocular muscle that results in a vision
				change for which eyeglasses are medically indicated within six (6) months of
				the surgery and is in accordance with rules established by Medicaid,
				or
B. One (1) pair of eyeglasses
				every five (5) years and in accordance with rules established by Medicaid. In
				either instance, the eyeglasses must be prescribed by a physician skilled in
				diseases of the eye or an optometrist, whichever the beneficiary
				selects.
C. Eye exams for all
				eligible beneficiaries are covered.
Miss. Code Ann. §
										43-13-121;
				  43-113-117(11);
				  42 CFR 441.30
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 1 - General › Rule 23-217-1.2 - Provider Enrollment

Current through June 25, 2024
A. Providers of
				vision services, and those who dispense optical items such as eyeglasses and
				contacts must satisfy all requirements set forth in Part 200, Chapter 4, Rule
				4.8 in addition to the following provider type specific requirements:
1. National Provider Identifier (NPI),
				verification from National Plan and Provider Enumeration System
				(NPPES),
2. Copy of licensure card
				or letter from the appropriate board stating current certification. Card or
				letter must be from state of servicing location, and
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
				noted on the W-9.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 1 - General › Rule 23-217-1.3 - Reimbursement

Current through June 25, 2024
A. Medicaid covers vision services under a
				statewide uniform fixed fee schedule for the professional services of the
				optometrist or ophthalmologist plus actual acquisition cost for eyeglass frames
				and lenses. The provider of eyeglasses must bill the actual acquisition cost
				(AAC) for the frames and lenses. Medicaid will cover the frames and lenses
				based on the lower of AAC or the maximum fee as determined by Medicaid.
				Effective as of July 1, 2021 all rates and/or fees for items and services will
				remain the same as those in effect for State Fiscal Year (SFY) 2021.
B. Medicaid does not permit providers of
				optometric services to charge a beneficiary an additional amount for services
				or supplies, like frames, above the fee established. The provider cannot
				dispense a more expensive frame than is covered under the Medicaid program and
				collect the difference from the beneficiary.
C. A beneficiary may purchase non-covered
				services, like scratch resistant lens coating. Providers cannot bill Medicaid
				and hold the eyeglasses or contacts until Medicaid pays the provider. Providers
				may not bill Medicaid for replacement costs associated with provider error or
				poor workmanship.
Miss. Code
				  Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 1 - General › Rule 23-217-1.4 - Non-Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid does not cover vision services including, but not limited to, eye
				exams, eyeglasses, frames, lenses, and/or contact lenses, for beneficiaries
				enrolled in the Family Planning Waiver (FPW).
B. The Division of Medicaid does not cover
				the following including, but not limited to:
1. Eyeglasses solely for protective, fashion,
				cosmetic, sports, occupational or vocational purposes,
2. More than one (1) pair of eyeglasses every
				five (5) years,
3. Single vision
				eyeglasses in addition to multifocal eyeglasses,
4. Progressive bifocals,
5. Sunglasses,
6. Upgraded frames,
7. Eyeglass cases,
8. Engraving,
9. Contact lens supplies and/or solutions,
10. Eyeglass or contact lens
				insurance,
11. Lens coating,
				unless specified by a Utilization Management/Quality Improvement Organization
				(UM/QIO), the Division of Medicaid, or designated entity,
12. Orthoptics,
13. Dispensing fees,
14. Contact lenses, unless specified by a
				UM/QIO, the Division of Medicaid, or designated entity,
15. Refractive surgery including, but not
				limited to, Lasik surgery, radial keratotomy, photorefractive keratectomy,
				and/or astigmatic keratotomy,
16.
				Services and items requiring prior authorization for which authorization has
				been either denied or not requested, or
17. Replacement of lenses or frames due to:
a Provider error in prescribing, frame
				selection, or measurement, or
b
				Poor workmanship and/or materials.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 1 - General › Rule 23-217-1.5 - Eye Examinations/Refractions

Current through June 25, 2024
A. Medicaid
				requires eye examinations/refractions to be performed by an optometrist or an
				ophthalmologist. Medicaid covers for one (1) refraction every five (5) years.
				No prior authorization is required. The appropriate procedure code must be
				billed.
B. Medicaid covers
				medically necessary diagnostic services that aid in the evaluation, diagnosis,
				and or treatment of ocular disease or injury for all beneficiaries regardless
				of age. Coverage is limited to the eye examination. The exam counts toward the
				sixteen (16) physician office visits. Providers must bill using the appropriate
				procedure codes for new and established patients.
42 CFR §
											441.30; Miss. Code Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 1 - General › Rule 23-217-1.6 - Lacrimal Punctum Plugs

Current through June 25, 2024
A. Medicaid covers
				medically necessary insertion of collagen and silicone punctum plugs when there
				is a documented diagnosis consistent with moderately severe to severe dry eye
				syndrome. A signed treatment/surgical consent form, specific to plug insertion,
				is required.
B. Medicaid does not
				cover the following:
1. Insertion of silicone
				plugs less than ten (10) days following collagen plug insertion,
2. Insertion of plugs for the treatment of
				any condition other than dry eye syndrome, contact lens intolerance, refractive
				correction, glaucoma, or sinus maladies,
3. Repetitive use of temporary or dissolvable
				collagen plugs when semi-permanent or permanent treatment is
				indicated,
4. Repetitive use of
				semi-permanent or non-dissolvable silicone plugs when there is an absence of
				documentation to support the need, such as plug fell out, and/or when permanent
				treatment is indicated, or
5.
				Separate reimbursement for the plug itself or when the cost of the plug is
				included in payment for the insertion.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 1 - General › Rule 23-217-1.7 - Documentation

Current through June 25, 2024
Records must be documented and maintained in accordance with
				  Part 200, Chapter 1, Rule 1.3. The vision medical record documentation must
				  contain the following on each beneficiary:
A. Date(s) of service,
B. Demographic information,
C. Current medical history,
D. Examination and/or treatment
				rendered,
E. Specific name/type of
				all diagnostic studies, and the result/finding of the studies,
F. Specific order for all lenses, lens
				coating, and ocular prosthetics, and
G. Provider's signature.
Miss. Code Ann. §
										43-13-121;
				  43-13-117; 43-13-118; 43-13-129 :
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 1 - General › Rule 23-217-1.8 - Dual Eligibles

Current through June 25, 2024
A. Medicare covers
				vision services provided to dual eligible beneficiaries, in accordance with the
				rules outlined in this Part, for services not covered by Medicare when the
				reason for the Medicare denial is other than medical necessity.
B. Dual eligible beneficiaries cannot be
				billed the balance between standard and deluxe frames as the Medicare and
				Medicaid payment is considered payment in full.
C. Providers must adhere to the rules for
				Third Party billing outlined in Part 306.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 1 - General › Rule 23-217-1.9 - 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 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 217 - Vision Services › Chapter 2 - Contact Lenses › Rule 23-217-2.1 - Coverage Criteria

Current through June 25, 2024
A. Medicaid does
				not cover contact lenses when prescribed for routine correction of refractive
				errors.
B. Medicaid covers contact
				lenses prescribed by an ophthalmologist or an optometrist when there is
				documentation that supports the following criteria:
1. Conventional eyeglasses will not result in
				acceptable visual correction, and
2. Contact lenses are medically necessary for
				the treatment of the following diseases or injury to the eye:
a) Keratoconus,
b) Keratoglobus,
c) Irregular cornea astigmatism,
d) Nystagmus,
e) Progressive myopia over 6 diopters, where
				contact lens will improve visual acuity or retard the progressive myopia and
				lessen the frequency of prescription changes,
f) Hyperopia over 3.5 diopters, where contact
				lenses will improve visual acuity,
g) Anisometropia greater than 3 diopters or
				greater than 2.5, if there is documented intolerance to glasses as a result of
				anisometropia,
h) Disease or
				deformity of the nose, skin, or ears that precludes the wearing of
				eyeglasses,
i) Post-operative
				cataract surgery, or
j) Treatment
				as a result of eye surgery, other than cataracts, which must be provided within
				six (6) months of the surgery to be covered.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 2 - Contact Lenses › Rule 23-217-2.2 - 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 217 - Vision Services › Chapter 3 - Eyeglasses › Rule 23-217-3.1 - Coverage Criteria

Current through June 25, 2024
A. Medicaid covers
				eyeglasses prescribed by an ophthalmologist or optometrist when documentation
				supports the following:
1. Eyeglasses are
				medically necessary,
2. Eyeglasses
				are prescribed to significantly improve vision or correct a medical condition,
				and
3. Eyeglasses meet eyeglass
				program specifications for frames and lenses.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 3 - Eyeglasses › Rule 23-217-3.2 - Lens Coating

Current through June 25, 2024
A. For purposes of
				this rule the following definitions will apply:
1. Antireflective is a coating applied to a
				lens to reduce the amount of reflected light and glare that reaches the
				eye.
2. Mirror coating is applied
				to a lens that allows the lens to take on the properties of a two-way
				mirror.
3. Scratch resistant
				coating is applied to a lens that helps retard crazing of the lens, thus
				extending the product life.
4. Tint
				is an opaque or transparent color coating applied to a lens. The parts of the
				light spectrum that are absorbed by the lens are determined by the color of the
				tint.
5. Photochromatic coating is
				applied to a lens that allows the lens to adjust to the amount of available
				light.
6. Polarized coating is
				applied to a lens that filters out reflected light and glare.
7. UV coating is applied to a lens to filter
				out ultraviolet light.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 3 - Eyeglasses › Rule 23-217-3.3 - Cataract/Ocular Surgery

Current through June 25, 2024
A. Medicaid covers
				eyeglasses, including the frames and lenses for beneficiaries who have had
				surgery on the eyeball or ocular muscle. The surgical benefit will be applied,
				regardless of whether the beneficiary has received eyeglasses during the
				benefit period, when all of the following criteria are met:
1. Surgery results in a vision
				change,
2. Eyeglasses are medically
				indicated within six (6) months of the surgery, and
3. Eyeglasses are prescribed by an
				optometrist or ophthalmologist.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 217 - Vision Services › Chapter 3 - Eyeglasses › Rule 23-217-3.4 - 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 218 - Hearing Services › Chapter 1 - General › Rule 23-218-1.1 - Provider Enrollment Requirements

Current through June 25, 2024
A. State-licensed
				audiologists and physicians must render services under their license as an
				audiologist or physician.
B. All
				providers of Medicaid services must comply with the requirements for enrollment
				as outlined in Part 200, Chapter 4, Rule 4.8. Physicians must satisfy the
				additional provider type requirements outlined in Part 203, Chapter 1, Rule
				1.1. Audiologist and hearing aid dealers must satisfy the additional provider
				type requirements listed below:
1. National
				Provider Identifier (NPI), verification from National Plan and Provider
				Enumeration System (NPPES),
2. Copy
				of current license in the state in which the individual furnishes the
				services,
3. Verification of having
				met the following requirements:
a) A master's
				or doctoral degree in audiology,
b)
				Has received a license from a state that requires the following conditions be
				met for licensure:
1) Has a Certificate of
				Clinical Competence in Audiology granted by the American
				Speech-Language-Hearing Association for licensure, or
2) Has successfully completed a minimum of
				three hundred fifty (350) clock-hours of supervised clinical practicum, or is
				in the process of accumulating that supervised clinical experience under the
				supervision of a qualified master or doctor-level audiologist; performed at
				least nine (9) months of full-time audiology services under the supervision of
				a qualified master or doctoral-level audiologist after obtaining a master's or
				doctoral degree in audiology, or a related field; and successfully completed a
				national examination in audiology approved by the Secretary.
c) In the case of an individual
				who furnishes audiology services in a State that does not license audiologists,
				or an individual exempted from State licensure based on practice in a specific
				institution or setting, the individual must meet one (1) of the conditions in
				Part 218, Chapter 1, Rule 1.1.3(b).
4. Verification of a 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, for individual providers. The name noted on
				verification must match the name noted on the W-9.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 218 - Hearing Services › Chapter 1 - General › Rule 23-218-1.2 - Cochlear Implants

Current through June 25, 2024
A. Medicaid covers
				for unilateral cochlear implantation when there is documentation that
				demonstrates the procedure is medically necessary and would be beneficial in
				reducing limitations of hearing impairment.
B. The following must be documented by the
				surgeon and/or audiologist:
1. Severe to
				profound sensorineural hearing loss in both ears as defined by FDA criteria
				with a lack of benefit from a well-fitting aid,
2. Cognitive ability to use auditory clues,
				patient motivation and a willingness to undergo an extended program of
				rehabilitation,
3. Freedom from
				middle ear infection, an accessible cochlear lumen that is structurally suited
				to implantation and freedom from lesions in the auditory nerve and acoustic
				areas of the central nervous system,
4. No contraindications to surgery,
				and
5. The device must be used in
				accordance with the FDA approved labeling.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 218 - Hearing Services › Chapter 1 - General › Rule 23-218-1.3 - Implantable and Non-Implantable Auditory Osseointegrated Device (AOD)

Current through June 25, 2024
A. The Division of Medicaid defines an
				implantable auditory osseointegrated device (AOD) as a surgically implantable
				hearing system which transmits sound vibrations through a sound processor to
				the inner ear by direct bone conduction through the skull.
1. The Division of Medicaid covers
				implantable AODs in accordance with the Food and Drug Administration (FDA)
				approved labeling in an Ambulatory Surgical Center (ASC) and the outpatient
				hospital setting for beneficiaries five (5) years of age and older with
				conductive, mixed, or single-sided sensorineural hearing loss who can benefit
				from sound amplification, meets FDA approved audiologic criteria for the
				prescribed implantable AOD, and meets at least one (1) of the following
				conditions:
a) Congenital, surgical, or
				acquired malformation(s) of the external ear canal or middle ear,
b) Severe chronic otitis externa or otitis
				media with persistent otorrhea and documented failure with air conducted
				hearing aids,
c) Tumors of the
				external ear canal and/or tympanic cavity,
d) Dermatitis of the external canal, or
e) Other anatomic or medical
				conditions in which an air conduction hearing aid is contraindicated.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 218 - Hearing Services › Chapter 1 - General › Rule 23-218-1.4 - 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 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.1 - Provider Enrollment Requirements

Current through June 25, 2024
Independent laboratory providers must satisfy all
				  requirements set forth in 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 tax identification number and legal name,
				and
C. CLIA certificate and
				completed Certification form, if applicable.
Miss. Code Ann. §
										43-13-121;
				  42 CFR 455, Subpart E; Social Security Act §
				  1902(a)(9)(c)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.2 - Independent Laboratory Services

Current through June 25, 2024
The Division of Medicaid does not reimburse independent
				  laboratories for lab procedures performed for beneficiaries during an inpatient
				  hospital stay. The All Patient Refined Diagnosis-Related Group (APR-DRG)
				  payment that the hospital receives is considered to cover all services provided
				  during the inpatient hospital stay. The hospital is responsible for
				  reimbursement to independent laboratories.
SPA 2012-008; Miss. Code
				  Ann. §§ 43-13 117, 121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.3 - Routine Venipuncture

Current through June 25, 2024
Medicaid covers routine venipuncture performed for the
				  purpose of obtaining a blood sample for laboratory testing as follows:
A. Routine venipuncture must be billed with
				appropriate procedure code.
B.
				Physicians, nurse practitioners, physician assistants, hospitals, and
				independent laboratories are covered one (l) for routine venipuncture only if
				the blood sample is drawn and all of it is referred to a separate,
				non-affiliated laboratory. If all or part of the sample is retained for a test
				to be performed in the facility where the venipuncture was performed, the
				physicians, nurse practitioners, physician assistants, hospitals, and
				independent laboratories are not covered for the venipuncture.
C. EPSDT screening providers are covered for
				routine venipuncture when performed for lead screening and/or RPR screening
				only if the blood sample is drawn and all of it is referred to a separate,
				non-affiliated laboratory. If all or part of the sample is retained for a test
				to be performed in the facility where the venipuncture was performed, the
				provider is not covered for the venipuncture.
D. The Mississippi State Department of Health
				(MSDH), Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC)
				providers who are reimbursed an encounter rate are not covered separately for
				performance of routine venipuncture during the same encounter.
E. Finger/heel/ear sticks that are performed
				for the purpose of collecting blood specimens or obtaining blood specimens via
				a partially or completely implantable venous access device are not
				covered.
F. Dialysis facilities
				will not be reimbursed outside the composite rate.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.4 - Independent Diagnostic Testing Facilities and Other Independent Mobile Diagnostic Units

Current through June 25, 2024
A. Medicaid only
				covers Independent Diagnostic Testing Facilities (IDTF), or other independent
				mobile diagnostic units, including portable x-ray providers, for services
				provided to dual-eligible beneficiaries. Outpatient testing and diagnostic
				services are covered when ordered by the beneficiary's physician and billed by
				an approved Medicaid provider, limited to physicians, physician clinics,
				Federally Qualified Health Centers, Rural Health Clinics, and county health
				department clinics.
B. An IDTF is
				defined by the Centers for Medicare and Medicaid Services (CMS) as "a fixed
				location, a mobile entity, or an individual non-physician practitioner. It is
				independent of a physician's office or hospital." These providers perform
				diagnostic tests such as ultrasounds, echocardiograms, pulmonary function
				tests, neurological and neuromuscular tests, x-rays, cardiac monitoring, and
				nuclear medicine.
C. Medicaid
				covers for a physician to contract with an IDTF or other independent mobile
				diagnostic unit to provide technical services and, assuming that there are no
				Stark II or other anti-kickback statute violations, allows for a claim to be
				filed for either the technical component or the complete procedure if the
				physician also interprets the procedure.
D. The physician contracting with an IDTF or
				other independent mobile diagnostic unit may not be employed by or own any part
				of the IDTF or other independent mobile diagnostic unit.
E. IDTFs and other independent mobile
				diagnostic units may not pay an additional fee to any physician when they
				perform the technical component of the procedure.
Miss. Code Ann. §
										43-13-121;
				  42 CFR
				  410.33
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.5 - Trofile Assay

Current through June 25, 2024
A. The "Trofile
				Assay" is covered for beneficiaries who are HIV-positive and diagnosed with
				Acquired Immune Deficiency Syndrome (AIDS) who have evidence of viral
				replication and HIV-1 strain resistance to multiple anti-retroviral
				agents.
B. Medicaid covers "Trofile
				Assay" for beneficiaries age sixteen (16) and over with the following
				restrictions/guidelines:
1. The assay is to be
				obtained only in anticipation of treatment of HIV/AIDS patients with CCR5
				antagonist agents who:
a) Are "treatment
				experienced" defined as having been previously treated with anti-retroviral
				regimen(s),
b) Have never received
				Maraviroc/Selzentry or other CCR5-antagonist agents, and
c) Have been deemed to have "virologic
				failure," or failed to obtain sufficiently low HIV viral loads despite prior
				appropriate anti-retroviral therapy.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.6 - Paternity Testing

Current through June 25, 2024
A. Medicaid defines
				paternity testing as any laboratory test used to establish the genetic
				relationship between an alleged father and a child.
B. Medicaid does not cover Paternity
				testing.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.7 - Qualitative Drug Screening

Current through June 25, 2024
A. Medicaid will
				cover medically necessary qualitative drug screens for:
1. Suspected drug overdose, and one (1) or
				more of the following conditions are present:
a) Unexplained coma,
b) Unexplained altered mental
				status,
c) Severe or unexplained
				cardiovascular instability, or cardiotoxicity,
d) Unexplained metabolic or respiratory
				acidosis,
e) Unexplained head
				trauma with neurological signs and symptoms, and/or
f) Seizures with an undetermined
				history.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.8 - 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 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.9 - Genetic Testing

Current through June 25, 2024
A. The Division of
				Medicaid defines genetic testing as a type of analysis that identifies changes
				in chromosomes, genes, or proteins that confirms or rules out a suspected
				genetic condition.
B. The Division
				of Medicaid covers genetic testing when medically necessary to establish a
				diagnosis of an inheritable disease only when all of the following are met:
1. The beneficiary displays clinical
				features, or is at direct risk of inheriting the mutation in question
				(pre-symptomatic),
2. The result of
				the test will directly guide the treatment being delivered to the beneficiary,
				and
3. After history, physical
				exam, pedigree analysis, genetic counseling, and completion of conventional
				diagnostic studies, a definitive diagnosis remains uncertain.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 219 - Laboratory Services › Chapter 1 - General › Rule 23-219-1.10 - Tuberculosis (TB) Testing

Current through June 25, 2024
A. The Division of
				Medicaid covers the following tuberculosis (TB) tests when a beneficiary has an
				increased risk for TB infection, as determined by the Centers for Disease
				Control and Prevention (CDC) and state law, and is administered in compliance
				with CDC recommendations and guidelines:
1.
				Mantoux tuberculin skin test (TST), and
2. Interferon-gamma release assays (IGRA).
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 220 - Radiology › Chapter 1 - General › Rule 23-220-1.1 - Provider Enrollment Requirements

Current through June 25, 2024
A. Radiology
				providers must satisfy all requirements set forth in Part 200, Chapter 4, Rule
				4.8 in addition to the following provider type specific requirements:
1. National Provider Identifier (NPI),
				verification from National Plan and Provider Enumeration System
				(NPPES),
2. Written confirmation
				from the IRS confirming the provider's tax identification number and legal
				name, and
3. Clinical Laboratory
				Improvement Amendments (CLIA) certificate and completed Certification form, if
				applicable.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 220 - Radiology › Chapter 1 - General › Rule 23-220-1.2 - Prior Authorization

Current through June 25, 2024
A. Effective July
				1, 2013, prior authorization is required by the radiology Utilization
				Management/Quality Improvement Organization (UM/QIO) for medical necessity and
				appropriateness of the service for the following advanced imaging procedures:
1. Computed Tomography (CT) Scans and
				Computed Tomography Angiography (CTA),
2. Magnetic Resonance Imaging (MRI) and
				Magnetic Resonance Angiography (MRA),
3. Positron Emission Tomography (PET) Scans,
				and
4. Nuclear Cardiac Imaging
				Studies.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 220 - Radiology › Chapter 1 - General › Rule 23-220-1.3 - Radiopharmaceuticals

Current through June 25, 2024
A. The Division of Medicaid covers
				radiopharmaceuticals administered for diagnostic or therapeutic purposes
				separately from the diagnostic procedure or visit.
1. Only the units administered are
				covered.
2. Radiopharmaceuticals
				must be approved by the (FDA), used in accordance with FDA approved conditions,
				and be administered in dosages that meet FDA regulations.
3. Radiopharmaceuticals considered
				experimental, investigative, or in clinical trial are not covered.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 220 - Radiology › Chapter 1 - General › Rule 23-220-1.5 - Port Films

Current through June 25, 2024
Medicaid does not
				  cover the review and interpretation of port films, referred to as the
				  professional component.
B. Medicaid
				covers the taking of the port film, one (1) unit for every five (5) treatments,
				referred to as the technical component.
C. Multiple treatments representing two (2)
				or more treatment sessions furnished on the same day are covered if the medical
				record contains documentation of a distinct break in therapy sessions and the
				treatments are of the character usually furnished on different days.
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 220 - Radiology › Chapter 1 - General › Rule 23-220-1.6 - 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 220 - Radiology › Chapter 1 - General › Rule 23-220-1.7 - Computed Tomography (CT) Scans and Computed Tomography Angiography (CTA)

Current through June 25, 2024
A. Effective July 1, 2013, Computed
				Tomography (CT) scans and Computed Tomography Angiography (CTA), with or
				without contrast, must be prior authorized by the radiology UM/QIO as noted in
				Rule 1.2.
B. The Division of
				Medicaid does not cover:
1. A limited or
				follow-up CT scan for any given area of the body during the same encounter as a
				full diagnostic CT scan,
2. A two
				(2)-dimensional rendering after a three (3)-dimensional rendering of a CT
				scan,
3. A CT/SPECT (Single Photon
				Emission Computed Tomography) nuclear medicine imaging only for:
a) Localization, or
b) Attenuation correction purposes,
3. A whole body CT for
				screening of asymptomatic beneficiaries, or
4. The performance of CT screenings in
				healthy beneficiaries.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 220 - Radiology › Chapter 1 - General › Rule 23-220-1.8 - Magnetic Resonance Angiography (MRA) and Magnetic Resonance Imaging (MRI)

Current through June 25, 2024
A. Effective July
				1, 2013, Magnetic Resonance Angiography (MRA) and Magnetic Resonance Imaging
				MRI), with or without contrast, must be prior authorized by the radiology
				UM/QIO as noted in Rule 1.2.
B. The
				Division of Medicaid covers a functional MRI when used as part of a
				preoperative evaluation for a planned craniotomy and is required for
				localization of eloquent areas of the brain, such as those responsible for
				speech, language, motor function, and senses, which might potentially be put at
				risk during the proposed surgery.
C. The Division of Medicaid does not cover an
				MRA or MRI for:
1. Screening of asymptomatic
				beneficiaries,
2. Screening of
				healthy beneficiaries, or
3. A two
				(2)-dimensional rendering after a three (3)-dimensional rendering has been
				performed.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 220 - Radiology › Chapter 1 - General › Rule 23-220-1.9 - Positron Emission Tomography (PET) Scans

Current through June 25, 2024
A. Effective
				July 1, 2013, Positron Emission Tomography (PET) scans must be prior authorized
				by the radiology UM/QIO as noted in Rule 1.2.
B. The Division of Medicaid covers one (1)
				fluorodeoxyglucose (FDG) PET scan for solid tumors, myeloma or lymphoma that
				are biopsy proven or strongly suspected based on other diagnostic testing for
				the following therapeutic purposes related to the initial treatment strategy to
				determine:
1. Whether or not the beneficiary
				is an appropriate candidate for an invasive diagnostic or therapeutic
				procedure,
2. Optimal anatomic
				location for an invasive procedure, or
3. The anatomic extent of a tumor when the
				recommended anti-tumor treatment reasonably depends on the extent of the
				tumor.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 220 - Radiology › Chapter 1 - General › Rule 23-220-1.10 - Nuclear Cardiac Imaging Studies

Current through June 25, 2024
A. Effective July
				1, 2013, nuclear cardiac imaging studies must be prior authorized by the
				radiology UM/QIO as noted in Rule 1.2.
B. The Division of Medicaid covers the
				following nuclear cardiac imaging:
1.
				Perfusion of the heart, either at rest or with pharmacological stress, for the
				diagnosis and management of beneficiaries with known or suspected coronary
				artery disease when one (1) of the following criteria are met:
a) The PET scan, whether at rest alone or at
				rest with stress, is performed in place of, but not in addition to, a single
				photon emission computed tomography (SPECT) scan, or
b) The PET scan, whether at rest alone or at
				rest with stress, is performed following an inconclusive SPECT scan.
1) The PET scan must be considered medically
				necessary to determine what medical or surgical intervention is required to
				treat the beneficiary.
2) The
				Division of Medicaid defines an inconclusive SPECT scan as a test(s) whose
				results are equivocal, technically uninterpretable, or discordant with a
				beneficiary's other clinical data documentation in the beneficiary's medical
				record.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 220 - Radiology › Chapter 1 - General › Rule 23-220-1.11 - Documentation

Current through June 25, 2024
A. Documentation for advanced imaging
				procedures must:
1. Include the referring
				physician, nurse practitioner or physician's assistant documentation of medical
				necessity and criteria met in Rule 1.2,
2. Not duplicate other covered diagnostic
				tests,
3. Be maintained in the
				referring provider's file,
4.
				Include documentation the procedure involved only FDA approved drugs and
				devices and did not involve investigational drugs, as determined by the
				FDA,
5. Support the referral to the
				rendering provider, and
6. Be
				maintained in accordance with Part 200, Chapter 3, Rule 1.3.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 221 - Family Planning and Family Planning Related Services › Chapter 1 - Family Planning and Family Planning Related State Plan Services › Rule 23-221-1.1 - Purpose

Current through June 25, 2024
The Division of Medicaid covers family planning and family
				  planning related State Plan services and supplies, directly or under
				  arrangements with others, to individuals capable of reproduction, including
				  minors who can be considered to be sexually active, who are eligible under the
				  State Plan and who desire such services and supplies.
42 USC § 1396 a;
				  Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 221 - Family Planning and Family Planning Related Services › Chapter 1 - Family Planning and Family Planning Related State Plan Services › Rule 23-221-1.2 - Freedom of Choice

Current through June 25, 2024
A. Medicaid
				beneficiaries have the right to freedom of choice of providers for Medicaid
				covered services in accordance with Miss. Admin. Code Part 200, Rule 3.6.
B. Beneficiaries have freedom of
				choice to:
1. Receive or reject family
				planning and family planning related services,
2. Choose family planning and family planning
				related services providers, and
3.
				Choose any method of birth control, including sterilization.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 221 - Family Planning and Family Planning Related Services › Chapter 1 - Family Planning and Family Planning Related State Plan Services › Rule 23-221-1.3 - Beneficiary Cost Sharing

Current through June 25, 2024
Family planning and family planning related services are
				  exempt from cost sharing (co-pay) requirements in accordance with Miss. Admin.
				  Code Part 200, Rule 3.7.
42 USC § 1396 a; 42
				  CFR §§447.50 - 447.57; Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 221 - Family Planning and Family Planning Related Services › Chapter 1 - Family Planning and Family Planning Related State Plan Services › Rule 23-221-1.4 - Covered Services

Current through June 25, 2024
A. Family planning
				and family planning related services are available for eligible beneficiaries
				who voluntarily choose to:
1. Prevent
				pregnancy,
2. Plan the number of
				pregnancies, or
3. Plan the
				spacing between pregnancies.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 221 - Family Planning and Family Planning Related Services › Chapter 1 - Family Planning and Family Planning Related State Plan Services › Rule 23-221-1.5 - Non-Covered Services and Items

Current through June 25, 2024
Services and items not considered family planning and family
				  planning related services include, but are not limited to:
A. Facilitating services, including, but not
				limited to, parking and child care while family planning and family planning
				related services are being obtained,
B. Indirect services including, but not
				limited to, telephone contacts/consultations,
C. Drugs used to promote fertility,
D. Emergency contraceptives and
				related services,
E.
				Over-the-counter drugs and supplies including, but not limited to, pregnancy
				tests and spermicides,
F.
				Infertility studies and procedures to enhance fertility including, but not
				limited to, reversal of sterilization, artificial or intrauterine insemination
				or in-vitro fertilization,
G.
				Abortions and related services,
H.
				Hysterectomy and related services for sterilization purposes,
I. Menopausal or post-menopausal treatment
				and related services,
J. Removal
				of an implanted device for a non-Medicaid eligible individual,
K. Natural family planning services,
L. Ultrasound and radiology
				services,
M. Cancer screening
				services, except for Pap smears,
N. Services to a beneficiary whose age or
				physical condition precludes reproduction,
O. Services to a beneficiary known to be
				pregnant,
P. Reversal of voluntary
				sterilization, or
Q. Services
				outside the scope and/or authority of the provider's specialty and/or area of
				practice.
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 221 - Family Planning and Family Planning Related Services › Chapter 1 - Family Planning and Family Planning Related State Plan Services › Rule 23-221-1.6 - Documentation/Record Maintenance

Current through June 25, 2024
A. Providers of
				family planning and family planning related services must comply with the
				requirements for maintenance of records outlined in Miss. Admin. Code Part 200,
				Rule 1.3.
B. Documentation of
				family planning and family planning related services must include, but are not
				limited to:
1. Signed and dated consent for
				treatment, if applicable,
2.
				Signed and dated consent for sterilization, if applicable, as outlined in Miss.
				Admin. Code Part 202, Rule 5.3.,
3. Date of service and reason for visit,
4. Demographic information,
				including name, address, Medicaid number, date of birth, sex, and marital
				status,
5. Comprehensive health
				history, updated at least annually, including, but not limited to:
a) Health risk factors,
b) Personal medical, sexual and contraceptive
				history,
c) Plans for having
				children, and
d) Obstetrical and
				gynecological history.
6. Complete family history, updated at least
				annually,
7. Allergies, including
				type, reaction, and treatment,
8.
				Specific name/type of all diagnostic studies, including, but not limited to,
				laboratory and the result/finding of the studies,
9. Treatments/procedures rendered,
10. Physical findings including vital signs
				and weight,
11. Documentation of
				all medications including contraceptives whether administered by the provider,
				prescribed, or issued via physician/prescriber samples, and must include, but
				not limited to:
a) The name,
b) Strength,
c) Dose,
d) Route of administration,
e) Site for all injectables, and
f) Manner in which prescription was issued
				including, but not limited to, in writing, by telephone, electronically or via
				facsimile.
12.
				Contraceptive supplies whether administered by the provider, prescribed, or
				issued via provider/prescriber samples,
13. Contraceptive devices,
14. Contraception counseling,
15. Date, time, and signature for all entries
				in the beneficiary's record, and
16. Provider's order, which must include the
				time, date, and signature, for all medications, treatments, and procedures
				rendered.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 221 - Family Planning and Family Planning Related Services › Chapter 1 - Family Planning and Family Planning Related State Plan Services › Rule 23-221-1.7 - 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 221 - Family Planning and Family Planning Related Services › Chapter 1 - Family Planning and Family Planning Related State Plan Services › Rule 23-221-1.8 - Reimbursement

Current through June 25, 2024
A. The Division of Medicaid reimburses for
				only the provider's whole acquisition cost (WAC) for physician administered
				drugs or implantable drug system devices.
B. The Division of Medicaid does not
				reimburse for provider/prescriber drug samples.
Miss. Code
				  Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 221 - Family Planning and Family Planning Related Services › Chapter 2 - 1115(a) Family Planning and Family Planning Related Waiver Services › Rule 23-221-2.1 - Purpose

Current through June 25, 2024
A. The Division of Medicaid covers family
				planning and family planning related waiver services and supplies, referred to
				as FPW in Miss. Admin. Code Part 221, Chapter 2, for all women and men, ages
				thirteen (13) through forty-four (44), who are capable of reproduction, who
				would not otherwise qualify for Medicaid, and with incomes at or below one
				hundred eighty-five percent (185%) of the federal poverty level, converted to a
				Modified Adjusted Gross Income (MAGI) equivalent standard through the 1115(a)
				Family Planning Waiver (FPW) Demonstration.
B. Providers are responsible for verification
				of covered FPW services and participant eligibility under the 1115(a) FPW
				Demonstration.
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 221 - Family Planning and Family Planning Related Services › Chapter 2 - 1115(a) Family Planning and Family Planning Related Waiver Services › Rule 23-221-2.2 - Eligibility

Current through June 25, 2024
A. The Family Planning Waiver (FPW) limits
				eligibility to individuals age thirteen (13) through forty-four (44) who are
				capable of reproducing and meet the following criteria:
1. Individual has a family income at or below
				one hundred eighty-five percent (185%) of the federal poverty level, converted
				to a Modified Adjusted Gross Income (MAGI) equivalent.
2. Female individual is not pregnant and has
				not had a medical procedure that would prevent pregnancy including, but not
				limited to, tubal ligation procedures, including tubal sterilization by
				hysteroscopy,
3. Male individual
				has not had a medical procedure that would prevent reproduction, including, but
				not limited to, a vasectomy,
4.
				Individual is uninsured and is not enrolled in Medicare, Medicaid, Children's
				Health Insurance Program (CHIP) or possesses other health insurance coverage
				that provides family planning and family planning related services,
5. Individual is a U.S. citizen or documented
				immigrant, and
6. Individual is a
				Mississippi resident.