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

Current through June 25, 2024
For the purpose of this fee schedule the following activities
				  have been defined:
Authorization.
An authorization is an approval
				  of medical services by a carrier/payer/employer, usually prior to service being
				  rendered.
Case Management.
The clinical and administrative
				  process in which timely, individualized, and cost effective medical
				  rehabilitation services are implemented, coordinated, and evaluated, by a
				  nurse, other case manager, or other utilization reviewer employed by the payer,
				  on an ongoing basis for patients who have sustained an injury or illness. Use
				  of case management is optional in Mississippi. Use state-specific code 9936M
				  for a conference with workers' compensation medical case manager/claims
				  manager.
Clinical Peer.
A health professional that holds
				  an unrestricted medical or equivalent license and is qualified to practice in
				  the same or similar specialty as would typically manage the medical condition,
				  procedures, or treatment under review. Generally, as a peer in a similar
				  specialty, the individual must be in the same profession (i.e., the same
				  licensure category as the ordering provider).
Clinical Rationale.
A statement or other
				  documentation that taken together provides additional clarification of the
				  clinical basis for a non-certification determination. The clinical rationale
				  should relate the non-certification determination to the worker's condition or
				  treatment plan, and must include a detailed basis for denial or
				  non-certification of the proposed treatment so as to give the provider or
				  patient a sufficient basis for a decision to pursue an appeal. Clinical
				  rationale must include specific reference to any applicable provisions of the
				  Mississippi Workers' Compensation Medical Fee Schedule which allegedly support
				  the determination of the reviewer, or a statement attesting to the fact that no
				  such provision(s) exists in the Fee Schedule.
Concurrent Review.
Certification or
				  Authorization review conducted during a worker's hospital stay or course of
				  treatment, sometimes called continued stay review.
Discharge Planning.
The process of assessing a
				  patient's need for medically appropriate treatment after hospitalization
				  including plans for an appropriate and timely discharge
*
Expedited Appeal.
An expedited appeal is a
				  request to reconsider a prior determination not to certify imminent or ongoing
				  services, an admission, an extension of stay, or other medical services of an
				  emergency, imminent, or ongoing nature.
First Level Clinical Review.
Review conducted by
				  a registered nurse, nurse case manager, or other appropriate licensed or
				  certified health professional. First level clinical review staff may approve
				  requests for admissions, procedures, and services that meet the standard of
				  medical necessity as defined elsewhere in the Fee Schedule, but must refer
				  requests that do not meet this medical necessity standard, in their opinion, to
				  second level clinical peer reviewers for approval or denial.
Notification.
Correspondence transmitted by
				  mail, telephone, facsimile, email, and/or other reliable electronic means.
Peer Review.
A review of any issue related to a
				  claim as requested by another party. (Not usually requested by the provider.)
Precertification.
The review and assessment of
				  proposed medical treatment or services before they occur to determine if such
				  treatment or services meet the definition of medical necessity as set forth
				  elsewhere in this Fee Schedule. The appropriateness of the site or level of
				  care is assessed along with the duration and timing of the proposed
				  services.
Provider.
A licensed health care facility,
				  program, agency, or health professional that delivers health care
				  services.
Retrospective Review.
Authorization review
				  conducted after services have been provided to the worker.
Second Level Clinical Review.
Peer review
				  conducted by appropriate clinical peers when the First Level Clinical Reviewer
				  is unable to determine whether a request for an admission, procedure, or
				  service satisfies the standard of medical necessity as defined elsewhere in
				  this Fee Schedule. A decision to deny, or not certify, proposed treatment or
				  services, must be supported by the express written evaluation, findings and
				  concurrence of a physician licensed to practice medicine in the State of
				  Mississippi and properly trained in the same specialty as the requesting
				  provider.
Standard Appeal.
A request by or on behalf of
				  the patient or provider to reconsider a prior decision by the payer or its
				  utilization review agent to deny proposed medical treatment or service,
				  including but not limited to, a determination not to certify an admission,
				  extension of stay, or other health care service.
Third Level Clinical Review.
Medical necessity
				  review conducted by appropriate clinical peers who were not involved in the
				  first or second level review when a decision not to certify a requested
				  admission, procedure, or service has been appealed. The third level peer
				  reviewer must be in the same or like specialty as the requesting provider. A
				  decision to deny, or not certify, proposed treatment or services, must be
				  supported by the express written evaluation, findings and concurrence of a
				  physician licensed to practice medicine in the State of Mississippi and
				  properly trained in the same specialty as the requesting provider.
Utilization Reviewer.
An entity, organization,
				  or representative/person performing authorization/pre-certification activities
				  or services on behalf of an employer, payer or third-party claims
				  administrator.
Variance.
A deviation from a specific
				  standard.