reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 1 - Inpatient Services › Rule 23-202-1.14 - Inpatient Hospital Payments

Current through June 25, 2024
A. For admissions
				dated October 1, 2012 and after, the Division of Medicaid reimburses all
				hospitals a per stay rate based on All Patient Refined Diagnosis Related Groups
				(APR-DRGs). APR-DRGs classify each case based on information contained on the
				inpatient Medicaid claim including diagnosis, procedures performed, patient
				age, patient sex, and discharge status. The APR-DRG payment is determined by
				multiplying the APR-DRG relative weight by the APR-DRG base rate. Medicaid uses
				a prospective method of reimbursement and will not make retroactive adjustments
				except as specified in the Title XIX Inpatient Hospital Reimbursement
				Plan.
B. The Division of Medicaid
				may adjust APR-DRG rates pursuant to changes in federal and/or state laws or
				regulations or to obtain budget goals. Effective July 1, 2021, all Plan changes
				must be authorized by the Mississippi Legislature and federal grantor agency,
				and rates shall not be increased, decreased or otherwise changed from the
				levels in effect on July 1, 2021, unless such changes are authorized by the
				Legislature.
C. Extraordinarily
				costly cases in relation to other cases within the same DRG because of the
				severity of the illness or complicating conditions may qualify for a cost
				outlier payment. This is an add-on payment for expenses that are not
				predictable by the diagnoses, procedures performed, and other statistical data
				captured by the DRG grouper.
1. The additional
				payment for a cost outlier is determined by calculating the hospital's
				estimated loss. The estimated loss is determined by multiplying the covered
				charges by the hospital's inpatient cost-to-charge ratio minus the DRG base
				payment. If the estimated loss is greater than the DRG cost outlier threshold
				established by the Division of Medicaid, then the cost outlier payment equals
				the estimated loss minus the DRG cost outlier threshold multiplied by the DRG
				Marginal Cost Percentage. For purposes of this calculation, the DRG base
				payment is net of any applicable transfer adjustment.
2. Stays assigned to mental health DRGs are
				not eligible for cost outlier payments, but may qualify for a day outlier
				payment if the mental health stay exceeds the DRG Long Stay
				Threshold.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 1 - Inpatient Services › Rule 23-202-1.16 - Split Billing

Current through June 25, 2024
A. Under Diagnosis
				Related Groups (DRG)-based payment, hospitals cannot split bill inpatient
				hospital Medicaid claims when a stay crosses a state fiscal year end, cost
				report year end, or under any other circumstance unless otherwise specified by
				the Division of Medicaid.
B. For
				Mississippi Medicaid, the seventy-two (72) hour observation stay is not
				considered a split bill.
C. Refer
				to Miss. Admin. Code Part 202, Rule
				1.14.E. for split billing of claims
				for services subject to the three (3) day window rule.
Miss. Code
				  Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 1 - Inpatient Services › Rule 23-202-1.17 - 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 this
				  Title, without regard to service limitations and with prior
				  authorization.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 1 - Inpatient Services › Rule 23-202-1.18 - Review for Medical Necessity and/or Independent Verification and Validation (IV&V)

Current through June 25, 2024
A. The Division of
				Medicaid defines Review for Medical Necessity and/or Independent Verification
				and Validation (IV&V) as the Utilization Management/Quality Improvement
				Organization (UM/QIO) or Division of Medicaid, or designee, review of services
				of Medicaid beneficiaries in the inpatient setting for including, but not
				limited to, the following:
1. Meeting clinical
				guidelines for medical necessity. [Refer to Part 200, Rule 5.1 for definition
				of medical necessity],
2.
				Appropriateness of setting and quality of care,
3. Appropriate lengths of stay and services,
				and
4. Correct All Patient Refined
				Diagnosis Related Groups (APR-DRG) assignment.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.1 - General

Current through June 25, 2024
Medicaid provides financial assistance for outpatient
				  hospital services. An outpatient is a person who is being provided services by
				  a hospital other than on an inpatient basis or for whom laboratory or radiology
				  services are performed for a referring physician. All rules set forth in Part
				  202, Chapter 1, are applicable to outpatient services in addition to those
				  specifically outlined in this chapter.
Miss. Code Ann. §
										43-13-121;
				  42 CFR §440.20(a)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.2 - Outpatient Hospital Services

Current through June 25, 2024
A. The Division of
				Medicaid covers outpatient hospital services provided by a licensed hospital in
				hospital outpatient departments to a beneficiary by or under the direction of a
				physician or dentist which are preventive, diagnostic, therapeutic,
				rehabilitative or palliative and include, but are not limited to:
1. Emergency department services,
2. Observation services,
3. Outpatient department services including
				same-day surgery,
4. Laboratory
				tests,
5. X-ray and other radiology
				services,
6. Medical
				supplies,
7. Physician-administered
				drugs and implantable drug system devices, and
8. Mental health services.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.3 - Emergency Department Outpatient Visits

Current through June 25, 2024
A. Emergency
				department services, also referred to as emergency room services, are allowed
				for all beneficiaries without limitations. Emergency department services
				provided by hospitals, except for Indian Health Services (IHS), are reimbursed
				using the outpatient prospective payment methodology. Effective as of July 1,
				2021 all rates and/or fees for services will remain the same as those in effect
				July 1, 2021.
B. The date of
				service for evaluation and management procedure code line items for outpatient
				hospital emergency department claims must be the date the beneficiary enters
				the emergency department even if the beneficiary's encounter spans multiple
				dates of service.
C. Services
				provided during an emergency department visit resulting in an inpatient
				hospital admission must be included on the inpatient hospital claim.
1. The "Statement Covers Period From Date" on
				the inpatient hospital claim is the first date the beneficiary enters the
				emergency department.
2. The
				Treatment Authorization Number (TAN) on the inpatient hospital claim is
				received from the Utilization Management and Quality Improvement Organization
				(UM/QIO), the Division of Medicaid, or a designated entity which corresponds
				with the date the physician documents the inpatient hospital admission in the
				physician's orders.
a) A TAN is not required
				for an emergency department visit.
b) A TAN issued by the UM/QIO, the Division
				of Medicaid, or a designated entity is only required for an inpatient admission
				or continued stay.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.4 - Outpatient Hospital Observation Services

Current through June 25, 2024
A. The Division of
				Medicaid defines outpatient hospital observation services as a well-defined set
				of specific, clinically appropriate services, which include ongoing short-term
				treatment, assessment, reassessment, and monitoring that are necessary to
				determine whether a beneficiary's condition requires further treatment as a
				hospital inpatient or allows for the beneficiary to be discharged from the
				hospital.
B. The Division of
				Medicaid covers outpatient hospital observation services for no more than
				seventy two (72) hours and must be documented in the physician's orders by the
				evaluating physician or other physician authorized by hospital bylaws to order
				outpatient hospital diagnostic tests or treatments, or an inpatient hospital
				admission. The decision for ordering outpatient hospital observation services
				or an inpatient hospital admission is solely the responsibility of the
				evaluating physician or authorized physician. Factors that must be taken into
				consideration by the evaluating physician or authorized physician when ordering
				outpatient hospital observation services include, but are not limited to,
1. Severity of the beneficiary's signs and
				symptoms,
2. Degree of medical
				uncertainty the beneficiary may experience an adverse occurrence,
3. Need for diagnostic studies that can be
				appropriately performed in the outpatient hospital setting and does not
				ordinarily require the beneficiary to remain at the hospital for more than
				seventy two (72) hours to assist in assessing whether the beneficiary must be
				admitted to inpatient hospital, and
4. Availability of diagnostic procedures at
				the time and location where the beneficiary seeks services.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.5 - Outpatient Dialysis

Current through June 25, 2024
Services provided in hospital-based renal dialysis units
				  (RDU) are covered and are not subject to any visit
				  limitations.
Miss. Code Ann. §
										43-13-121,
				  43-13-117(2)
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.6 - Mental Health Services

Current through June 25, 2024
A. Mental health
				services provided in an outpatient department of a general hospital are covered
				when:
1. Provided by appropriate staff
				operating within the scope of their practice,
2. Appropriate for the setting according to
				the licensure of the hospital,
3.
				Prior authorized by the Utilization Management and Quality Improvement
				Organization (UM/QIO).
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.7 - Out-of-State Facilities

Current through June 25, 2024
Out-of-state hospitals will be reimbursed using the same
				  methodology as Mississippi hospitals.
Miss. Code Ann. §
										43-13-121;
				  §
										43-13-117(A)(2)(c);
				  42 CFR §431.52
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.8 - Outpatient Hospital Rates

Current through June 25, 2024
The Division of Medicaid reimburses all outpatient hospital
				  services except for Indian Health Service Facilities, using the outpatient
				  prospective payment system (OPPS) methodology. Effective as of July 1, 2021 all
				  rates and/or fees for services will remain the same as those in effect July 1,
				  2021.
42
				  C.F.R. §
											447.321; Miss. Code Ann.
				  §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.9 - 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 this
				  Title, without regard to service limitations and with prior
				  authorization.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.10 - Phase II Cardiac Rehabilitation Services

Current through June 25, 2024
The Division of Medicaid defines Phase II Cardiac
				  Rehabilitation services as a physician supervised program designed to
				  recondition the cardiovascular system and restore beneficiaries with
				  cardiovascular heart disease to their optimal functional status including their
				  physiological, psychological, social, vocational and emotional status
				  including, but not limited to:
1.
				Formal exercise sessions with continuous electrocardiographic (ECG)
				monitoring,
2. Risk factor
				education, and
3. Behavior
				modification counseling.
Providers must comply with all requirements set forth in Part
				  200, Chapter 4, Rule 4.8 in addition to:
Being a current Mississippi Division of Medicaid
				  provider,
Being located in the state of Mississippi, and
Holding a current certification from the American Association
				  of Cardiovascular and Pulmonary Rehabilitation (AACVPR).
C. The Division of Medicaid covers Phase II
				Cardiac Rehabilitation services for beneficiaries eighteen (18) and older for
				one (1) of the qualifying episodes:
1. Acute
				myocardial infarction within the preceding twelve (12) months,
2. Coronary artery bypass graft within six
				(6) months,
3. Percutaneous
				transluminal coronary angioplasty or percutaneous coronary intervention within
				six (6) months,
4. Heart valve
				repair/replacement within six (6) months,
5. Heart transplant within one (1) year,
				or
6. Stable angina positive stress
				test within six (6) months.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.11 - Diabetes Self-Management Training (DSMT)

Current through June 25, 2024
Refer to Part 200, Chapter 5, Rule 5.6
42 CFR §410.141;
				  Miss. Code Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 2 - Outpatient Services › Rule 23-202-2.12 - Hospital-Based Physician Clinics

Current through June 25, 2024
A. The Division of
				Medicaid defines a provider-based entity as a hospital-based physician clinic
				that meets the Centers for Medicare and Medicaid Services (CMS) requirements to
				be considered provider-based.
B. A
				hospital cannot bill a hospital clinic evaluation and management code for
				hospital-based physician clinic services unless the hospital meets all of the
				following:
1. Is a teaching hospital within
				the state of Mississippi,
2. Has a
				medical resident-to-bed ratio of 0.25 or greater as derived from a calculation
				from the hospital provider's cost report, Worksheet E, Part A, Line 19,
3. Is located:
a) On the campus of the main provider's
				hospital facility, or
b) Within
				thirty-five (35) miles of the physician clinic if the physician clinic is
				located off campus.`
4.
				Meets the hospital-based determination as outlined in
				42
				C.F.R. §
											413.65(b), and
5. Meets and follows all Division
				of Medicaid rules and State and Federal regulations.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 3 - Swing Beds › Rule 23-202-3.1 - Definition

Current through June 25, 2024
Swing bed services are extended care services provided in a
				  hospital bed that has been designated as such. Services consist of one or more
				  of the following:
A. Skilled nursing
				care and related services for patients requiring medical or nursing
				care,
B. Rehabilitation services
				for the rehabilitation of injured, disabled, or sick persons, and
C. On a regular basis, health related care
				and services to individuals who, because of their medical status, require care
				and services above the level of room and board which can be made available to
				them only through institutional facilities.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 3 - Swing Beds › Rule 23-202-3.2 - Certification of Providers/ Provider Enrollment

Current through June 25, 2024
A. The Division
				of Medicaid requires any hospital certified for participation in the Medicare
				swing bed program who wants to participate in the Medicaid program to become a
				provider. A separate provider number from the hospital is required for the
				swing bed.
B. Hospital providers,
				including swing bed providers applying for enrollment into the Medicaid program
				must satisfy all requirements set forth in Part 200, Chapter 4, Rule 4.8 in
				addition to submitting 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
				business name.
3. CLIA certificate
				and submit the completed certification form.
4. Joint Commission on Accreditation of
				Health Care Organization (JCAHO) for licensed hospitals.
5. Copy of current Medicare certification or
				Tie-In Notice. Explanation of Medicare Benefits (EOMB) is not
				acceptable.
6. Copy of outstanding
				claims, if applicable, for out-of state facility.
7. Copy of Hospital license:
a.Copy of license/certification, in effect
				during the claims period for which they are billing for out-of state
				facility.
b. In-state facility: A
				copy of letter from the Mississippi State Department of Health is acceptable
				for in-state facility.
c. License
				in effect for the new owner for Hospital undergoing a Change of Ownership
				(CHOW).
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 3 - Swing Beds › Rule 23-202-3.3 - Coverage Criteria

Current through June 25, 2024
A. Swing bed
				services are covered when all these criteria are met:
1. Services to be furnished are ordered by a
				physician, are consistent with the nature and severity of the beneficiary's
				illness or injury, medical needs, and accepted standards of medical practice,
				and are reasonable in duration and quantity,
2. The beneficiary requires daily and
				continuous (not intermittent) skilled nursing and/or rehabilitation services to
				prevent or minimize deterioration or to sustain health status,
3. The beneficiary does not require daily
				supervision of a physician but does require a physician visit and evaluation at
				least every thirty (30) days while the beneficiary is in the swing bed
				setting,
4. A nursing facility bed
				is not available and the required services cannot be safely and effectively
				provided in the beneficiary's residence,
5. In addition to the need for skilled
				nursing and/or rehabilitation services, the beneficiary must require, at a
				minimum, assistance with at least three (3) activities of daily living (eating,
				toileting, personal hygiene, bathing, ambulation, dressing) which cannot be
				safely and cost-effectively provided in the beneficiary's residence and which
				must be performed by, or under the supervision of, registered nurses, licensed
				practical nurses, physical therapists, or occupational therapists.
6. Swing bed services may be covered as long
				as the beneficiary meets the coverage criteria and there is no available bed in
				a nursing facility. It is expected that the beneficiary will be discharged or
				transferred to a nursing facility when the beneficiary's condition allows or a
				nursing home bed becomes available.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 3 - Swing Beds › Rule 23-202-3.4 - Reimbursement

Current through June 25, 2024
A. Individuals who are placed in swing beds
				in a hospital may have Medicare only, Medicare and Medicaid, or Medicaid only.
1. In all instances where a Medicaid
				beneficiary is covered by Medicare, Medicare is the primary payer for a swing
				bed stay.
2. Medicaid covers swing
				bed care for Medicare and Medicaid dual eligibles when:
a) The Medicaid beneficiary's medical
				condition does not qualify for Medicare, or
b) Medicare benefits are exhausted.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 3 - Swing Beds › Rule 23-202-3.5 - Documentation Requirements

Current through June 25, 2024
A. The Division of
				Medicaid requires providers of swing bed services to maintain auditable records
				that substantiate the services provided. Refer to Maintenance of Records Part
				200, Ch.1, Rule 1.3. At a minimum, the records must contain the following on
				each beneficiary:
1. Date of
				service,
2. History and physical
				exam, with update if necessary,
3.
				Physician's progress notes,
4.
				Medical indication,
5. Results and
				finding of all diagnostic and lab procedures,
6. Treatment rendered,
7. Provider's signature or
				initials,
8. Documentation of
				services consisting of skilled nursing care and related services for patients
				requiring medical or nursing care,
9. Documentation of rehabilitation services
				for the rehabilitation of injured, disabled or sick persons, and
10. Frequent documentation of health related
				care and services to individuals who, because of their medical status, require
				care and services above the level of room and board which can be made available
				only through institutional facilities.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.1 - Transplant Provider Requirements

Current through June 25, 2024
Providers of transplant services must:
A. Complete the requirements for
				participation in the Mississippi Medicaid program.
B. Meet the following facility criteria:
1. Solid organ transplant procedures must be
				performed in a facility which meets the Centers for Medicare and Medicaid
				Services (CMS) requirements for Conditions of Participation approved as a
				transplant facility unless otherwise authorized by the Division of Medicaid,
				and
2. Bone marrow and stem cell
				transplant procedures must be performed in a facility accredited by a
				CMS-deemed national accreditation organization.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.2 - Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid covers the following solid organ transplant services when medically
				necessary and prior authorized by a Utilization Management/Quality Improvement
				Organization (UM/QIO), the Division of Medicaid, or designated entity:
1. Single organs:
a) Heart, according to current criteria of
				the International Society for Heart and Lung Transplantation,
b) Intestine, according to current criteria
				of the American Gastroenterological Association and American Society of
				Transplantation,
c) Liver,
				according to current criteria of the American Association for the Study of
				Liver Diseases and the American Society of Transplantation,
d) Single lung, according to current criteria
				of the Pulmonary Transplantation Council of the International Society for Heart
				and Lung Transplantation, and
e)
				Bilateral lung, according to current criteria of the Pulmonary Transplantation
				Council of the International Society for Heart and Lung Transplantation,
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.3 - Non-Covered Services

Current through June 25, 2024
The Division of Medicaid does not cover the following
				  transplant procedures/services including, but not limited to:
A. Transplant procedures/services not
				medically necessary,
B. Transplant
				procedures/services still in clinical trials and/or investigational or
				experimental in nature,
C.
				Transplant procedures/services performed in a facility not approved by the
				Division of Medicaid and/or meeting the criteria in Miss. Admin. Code Part 202,
				Rule
				4.1,
D. Inpatient admissions or outpatient
				procedures, if required, for transplant procedures/services that have not been
				prior authorized by a UM/QIO, the Division of Medicaid, or designated entity,
				or
E. Pancreas transplants.
Miss. Code Ann. §
											43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.4 - Reimbursement

Current through June 25, 2024
A. All fee-for-service (FFS) transplants
				performed in the state of Mississippi are paid under the Mississippi All
				Patient Refined-Diagnosis Related Group (APR-DRG) payment methodology,
				including a policy adjustor.
B. All
				FFS transplants available in Mississippi but performed outside the state of
				Mississippi are paid under the Mississippi APR-DRG payment methodology,
				including a policy adjustor.
C.
				Payment for transplant services not available in Mississippi is made under the
				Mississippi APR-DRG payment methodology including a policy adjustor. If the
				Mississippi APR-DRG payment limits access to care, a case rate may be set.
1. A case rate is set at forty percent (40%)
				of the sum of billed charges for transplant services as published in the State
				Plan according to
Milliman's U.S. Organ and Tissue Transplant Cost
				Estimates and Discussion
in effect as of July 1, 2019.
2. The
Milliman
categories
				comprising the sum of billed charges include outpatient services received
				thirty (30) days pre-transplant, procurement, hospital transplant inpatient
				admission, physician services during transplant and one-hundred eighty (180)
				days post (transplant) hospital discharge. Outpatient immunosuppressants and
				other prescriptions are not included in the case rate.
3. If the transplant hospital stay exceeds
				the hospital length of stay published by
Milliman
, an outlier
				per-diem payment will be made for each day that exceeds the hospital length of
				stay.
4. Reimbursement for
				transplant services cannot exceed one-hundred percent (100%) of the sum of
Milliman's
billed charges for the categories listed in Miss.
				Admin. Code Part 202, Rule 4.4.C.2.
5. Provisions listed in Miss. Admin. Code
				Part 202, Rule 4.4 apply to transplant services on or after October 1,
				2012.
6. Transplant services not
				available in Mississippi and not listed in the
Milliman's U.S. Organ
				and Tissue Transplant Cost Estimates and Discussion
will be reimbursed
				using the Mississippi APR-DRG payment methodology. If the Mississippi APR-DRG
				payment limits access to care, the Division of Medicaid will reimburse what the
				domicile state pays for the service.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.5 - Fundraising

Current through June 25, 2024
A. The Division of Medicaid allows
				fundraisers to obtain funds needed for transplant costs not covered by the
				Medicaid program.
B. Fundraising
				criteria includes, but is not limited to, the following:
1. Prior to accepting donations, arrangements
				must be made with the Division of Medicaid to deposit donations in a trust
				fund/special account.
2. The trust
				fund/special account must be established and administered in compliance with
				all applicable federal and state rules and regulations.
3. The trust fund/special account must be
				managed and administered by someone other than the beneficiary or the
				beneficiary's guardian, legal representative or family member. The beneficiary
				or the beneficiary's guardian, legal representative or family member cannot
				have direct access to the trust fund/special account.
4. Trust fund/special account must be
				maintained separately from personal monies belonging to the beneficiary or the
				beneficiary's guardian, legal representative or family member.
5. Legible and authentic documentation of
				income and expenditures must be made available to a Utilization
				Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid,
				or designated entity upon request.
6. The beneficiary must report all sources of
				income to the Division of Medicaid. Donated funds for the purpose of payment of
				medical services are considered a third party source.
7. Transplant facilities/providers cannot
				participate in fundraising for beneficiaries to raise additional funds to pay
				for the transplant procedure and/or related services.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.6 - Documentation Requirements

Current through June 25, 2024
Providers of transplant services must document and maintain
				  records in accordance with requirements set forth in Miss. Admin. Code Part
				  200, Rule
				  1.3 on each beneficiary receiving a
				  transplant and must include the following:
A. Comprehensive history and physical.
B. Treatments rendered that were
				unable to prevent progressive disability and/or death.
C. Use of tobacco, alcohol, and/or illegal
				drugs within the last six (6) months.
D. Absence of severe and irreversible organ
				dysfunction in organ(s) other than the organ(s) being transplanted.
E. Relevant diagnostic studies and results
				including, but not limited to:
1. X-rays,
2. Lab reports,
3. EKG reports,
4. Pulmonary function studies,
5. Psychosocial reports,
6. Nutritional evaluation, and
7. Performance status.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.7 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Current through June 25, 2024
The Division of Medicaid pays for all medically necessary
				  services for early and periodic screening, diagnosis, and treatment
				  (EPSDT)-eligible beneficiaries in accordance with Miss. Admin. Code Part 223,
				  without regard to service limitations and with prior authorization.
Miss. Code Ann.
				  §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.8 - 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 this
				  Title, without regard to service limitations and with prior
				  authorization.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.9 - Cornea Transplant

Current through June 25, 2024
Medicaid covers cornea transplants for all beneficiaries and
				  does not require prior authorization for medical necessity from the
				  UM/QIO.
Miss. Code Ann. §
										43-13-121;
				  42 CFR §482.90104
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.10 - Heart Transplant

Current through June 25, 2024
A. Prior
				authorization is required.
B. Heart
				transplants are covered when all the following criteria are met:
1. Candidate is less than sixty-six (66)
				years of age.
2. New York Heart
				Association (NYHA) Class III or IV on maximal medical therapy.
3. Meets transplanting facility's blood and
				tissue-type compatibility standards.
4. Infections are controlled for at least
				forty-eight (48) hours prior to transplant.
5. Pulmonary Functions studies of FEV1 of
				>1.5 liter, PVR of <3 Wood units (if >3, prior to vasodilators, <3
				after), Pulmonary artery systolic pressure <65-70 mm Hg.
6. Absence of irreversible and severe end
				organ dysfunction, such as hepatic, renal, peripheral vascular, or
				cerebrovascular, as well as, refractory hypertension, or uncontrolled
				malignancy.
7. All other treatments
				have been attempted or considered and none will prevent progressive disability
				and/or death.
8. The candidate
				and/or legal representative understands the transplant risks and benefits,
				gives informed consent, and has the capacity and is willing to comply with
				needed care, including immunosuppressive therapy.
9. The candidate has been approved by the
				transplant review team.
10.
				Required serology studies have been completed for HIV, Hepatitis A, B, and C,
				Cytomegalovirus (CMV), and Varicella.
11. Immunizations have been administered as
				follows:
a) All immunizations for children
				age two (2) to six (6) are up-to-date in accordance with the most current
				recommended childhood immunization schedule developed and endorsed by the
				Advisory Committee on Immunization Practices (ACIP), the American Academy of
				Pediatrics (AAP), and the American Academy of Family Physicians
				(AAFP),
b) Hepatitis A, if serology
				does not indicate immunity,
c)
				Hepatitis B, if serology does not indicate immunity,
d) Pneumococcal, and
e) Influenza, annually.
12. A psychosocial evaluation has been
				performed for the adult candidate or, if the candidate is a child, for the
				family, with the following results:
a)
				Candidate's psychiatric disorders, if present, are being treated,
b) Candidate's
s
ocial
				support system has been evaluated and found to be adequate, and
c) Candidate has no previous history of
				significant non-compliance to medical treatment.
13. Specific diagnostic inclusion criteria
				include the following conditions if expected to limit the candidate's survival
				rate to less than twelve (12) months:
a)
				Congestive, restrictive, or ischemic cardiomyopathy,
b) Valvular, congenital and other organic
				heart disease,
c) Recurrent and
				refractory life-threatening ventricular dysrhythmias, or
d) Refractory severe angina
				pectoris.
14. The
				facility is approved for heart transplants.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.11 - Heart/Lung Transplant

Current through June 25, 2024
A. Prior
				authorization is required.
B.
				Heart/lung transplants are covered when the following criteria are met:
1. Candidate is less than fifty-six (56)
				years of age.
2. NYHA Class III or
				IV with rehabilitation potential.
3. Preserved nutritional state.
4. Meets facility's blood and tissue-type
				compatibility standards.
5.
				Infections controlled for at least forty-eight (48) hours prior to transplant,
				unless the infection is limited to the lung to be removed.
6. Absence of irreversible and severe end
				organ dysfunction, including hepatic, gastrointestinal, renal, peripheral
				vascular, or cerebrovascular, or uncontrolled malignancy.
7. All other treatments have been attempted
				or considered and none will prevent progressive disability and/or
				death.
8. The candidate and/or
				legal representative understands the transplant risks and benefits, gives
				informed consent, and has the capacity and is willing to comply with needed
				care, including immunosuppressive therapy.
9. The candidate has been approved by the
				center's transplant review team.
10. Required serology studies have been
				completed for HIV, Hepatitis (A, B, and C), Cytomegalovirus (CMV), and
				Varicella.
11. Immunizations have
				been administered as follows:
a) All
				immunizations for children age two (2) to six (6) are up-to-date in accordance
				with the most current recommended childhood immunization schedule developed and
				endorsed by the Advisory Committee on Immunization Practices (ACIP), the
				American Academy of Pediatrics (AAP), and the American Academy of Family
				Physicians (AAFP).
b) Hepatitis A,
				if serology does not indicate immunity.
c) Hepatitis B, if serology does not indicate
				immunity.
d)
				Pneumococcal.
e) Influenza,
				annually.
12. A
				psychosocial evaluation has been performed for the adult candidate or, if the
				candidate is a child, for the family, with the following results:
a) Candidate's psychiatric disorders, if
				present, are being treated.
b)
				Candidate's social support system has been evaluated and found to be
				adequate.
c) Candidate has no
				previous history of significant non-compliance to medical treatment.
13. Specific Diagnostic Inclusion
				Criteria
a) End-stage fibrotic lung disease
				unresponsive to alternative therapy with FVC <65% of predicted.
b) End-stage obstructive lung disease with
				FVC <25% of predicted.
c)
				End-stage pulmonary hypertension, either primary or secondary without
				significant right heart dysfunction, unless heart-lung transplant
				planned.
d) Cystic fibrosis with
				FVC <40% and FEV1 <30% of predicted.
e) Bronchiectasis.
f) Bronchopulmonary dysplasia.
g) Obliterative bronchiolitis.
14. Facility must be approved for
				heart and lung transplants by Medicaid.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.12 - Kidney Transplant

Current through June 25, 2024
Medicaid covers kidney transplants for all beneficiaries and
				  does not require prior authorization for medical necessity from the
				  UM/QIO.
Miss. Code Ann. §
										43-13-121;
				  42 CFR §482.90104
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.13 - Liver Transplant

Current through June 25, 2024
A. Prior
				authorization is required.
B. Liver
				transplants are covered when the following criteria are met:
1. Candidate is less than sixty-five (65)
				years of age.
2. Model for End
				Stage Liver Disease (MELD) score.
3. Pediatric End Stage Liver Disease (PELD)
				score.
4. Meets transplant
				facility's blood and tissue-type compatibility standards.
5. Infection controlled for at least
				forty-eight (48) hours prior to transplant.
6. Absence of severe and irreversible end
				organ dysfunction, either cardiac, pulmonary, renal, peripheral vascular, or
				cerebrovascular, or uncontrolled extrahepatic malignancy.
7. All other treatments have been attempted
				or considered and none will prevent progressive disability and/or
				death.
8. The candidate and/or
				legal representative understands the transplant risks and benefits, gives
				informed consent, and has the capacity and is willing to comply with needed
				care, including immunosuppressive therapy.
9. The candidate has been approved by the
				transplant review team.
10.
				Required serology studies have been completed for HIV, Hepatitis A, B, and C,
				Cytomegalovirus (CMV), and Varicella.
11. Immunizations have been administered as
				follows:
a) All immunizations for children
				age two (2) to six (6) are up-to-date in accordance with the most current
				recommended childhood immunization schedule developed and endorsed by the
				Advisory Committee on Immunization Practices (ACIP), the American Academy of
				Pediatrics (AAP), and the American Academy of Family Physicians
				(AAFP),
b) Hepatitis A, if serology
				does not indicate immunity,
c)
				Hepatitis B, if serology does not indicate immunity,
d) Pneumococcal, and
e) Influenza, annually.
12. A psychosocial evaluation has been
				performed for the adult candidate or, if the candidate is a child, for the
				family, with the following results:
a)
				Candidate's psychiatric disorders, if present, are being treated.
b) Candidate's
s
ocial
				support system has been evaluated and found to be adequate.
c) Candidate has no previous history of
				significant non-compliance to medical treatment.
13. Specific Diagnostic Inclusion Criteria
a) Chronic progressive liver disease, not
				otherwise correctable, including cirrhosis due to: alcoholism, if abstinent at
				least the prior six (6) months, chronic hepatitis C, primary or secondary
				biliary disease, sclerosing cholangitis, inborn error of metabolism, or other
				causes.
b) Non-cirrhotic liver
				failure due to: biliary atresia, fulminant liver failure, submassive hepatic
				necrosis, hepatoblastoma, Budd-Chiari syndrome, an obstruction of the hepatic
				veins if associated with a treatable disorder.
c) Hepatocellular carcinoma, in conjunction
				with chemotherapy, if there is no evidence of extrahepatic
				metastases.
14. Facility
				is approved for liver transplants by the Division of Medicaid.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.14 - Single Lung Transplant

Current through June 25, 2024
A. Prior
				authorization is required.
B.
				Single lung transplants are covered when the following criteria are met:
1. Candidate is less than sixty-six (66)
				years of age.
2. NYHA Class III or
				IV with rehabilitation potential.
3. Preserved nutritional state.
4. Meets facility's blood and tissue-type
				compatibility standards.
5.
				Infections controlled for at least forty-eight (48) hours prior to transplant,
				unless the infection is limited to the lung to be removed.
6. Absence of irreversible and severe end
				organ dysfunction, either hepatic, gastrointestinal, renal, peripheral
				vascular, or cerebrovascular, or uncontrolled malignancy
7. All other treatments have been attempted
				or considered and none will prevent progressive disability and/or
				death.
8. The candidate and/or
				legal representative understands the transplant risks and benefits, gives
				informed consent, and has the capacity and is willing to comply with needed
				care, including immunosuppressive therapy.
9. The candidate has been approved by the
				center's transplant review team.
10. Required serology studies have been
				completed for HIV, Hepatitis A, B, and C, Cytomegalovirus (CMV), and
				Varicella.
11. Immunizations have
				been administered as follows:
a) All
				immunizations for children age two (2) to six (6) are up-to-date in accordance
				with the most current recommended childhood immunization schedule developed and
				endorsed by the Advisory Committee on Immunization Practices (ACIP), the
				American Academy of Pediatrics (AAP), and the American Academy of Family
				Physicians (AAFP)
b) Hepatitis A,
				if serology does not indicate immunity.
c) Hepatitis B, if serology does not indicate
				immunity.
d)
				Pneumococcal.
e) Influenza,
				annually
12. A
				psychosocial evaluation has been performed for the adult candidate or, if the
				candidate is a child, for the family, with the following results:
a) Candidate's psychiatric disorders, if
				present, are being treated.
b)
				Candidate's social support system has been evaluated and found to be
				adequate.
c) Candidate has no
				previous history of significant non-compliance to medical treatment.
13. Specific Diagnostic Inclusion
				Criteria
a) End-stage fibrotic lung disease
				unresponsive to alternative therapy with FVC <65% of predicted.
b) End-stage obstructive lung disease with
				FVC <25% of predicted.
c)
				End-stage pulmonary hypertension, either primary or secondary without
				significant right heart dysfunction, unless heart-lung transplant
				planned.
d) Cystic fibrosis with
				FVC <40% and FEV1 <30% of predicted.
e) Bronchiectasis.
f) Bronchopulmonary dysplasia.
g) Obliterative bronchiolitis.
14. Facility must be approved for
				lung transplants by the Division of Medicaid.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.15 - Bilateral Lung Transplant

Current through June 25, 2024
A. Prior
				Authorization is required.
B.
				Bilateral lung transplants are covered when the following criteria are met:
1. Candidate is less than sixty-one (61)
				years of age.
2. NYHA Class III or
				IV with rehabilitation potential.
3. Preserved nutritional state.
4. Meets facility's blood and tissue-type
				compatibility standards.
5.
				Infections controlled for at least forty-eight (48) hours prior to transplant,
				unless the infection is limited to the lung to be removed.
6. Absence of irreversible and severe end
				organ dysfunction, either hepatic, gastrointestinal, renal, peripheral
				vascular, or cerebrovascular), or uncontrolled malignancy.
7. All other treatments have been attempted
				or considered and none will prevent progressive disability and/or
				death.
8. The candidate and/or
				legal representative understands the transplant risks and benefits, gives
				informed consent, and has the capacity and is willing to comply with needed
				care, including immunosuppressive therapy.
9. The candidate has been approved by the
				center's transplant review team.
10. Required serology studies have been
				completed for HIV, Hepatitis (A, B, and C), Cytomegalovirus (CMV), and
				Varicella.
11. Immunizations have
				been administered as follows:
a) All
				immunizations for children age two (2) to six (6) are up-to-date in accordance
				with the most current recommended childhood immunization schedule developed and
				endorsed by the Advisory Committee on Immunization Practices (ACIP), the
				American Academy of Pediatrics (AAP), and the American Academy of Family
				Physicians (AAFP).
b) Hepatitis A,
				if serology does not indicate immunity.
c) Hepatitis B, if serology does not indicate
				immunity.
d)
				Pneumococcal.
e) Influenza,
				annually.
12. A
				psychosocial evaluation has been performed for the adult candidate or, if the
				candidate is a child, for the family, with the following results:
a) Candidate's psychiatric disorders, if
				present, are being treated.
b)
				Candidate's social support system has been evaluated and found to be
				adequate.
c) Candidate has no
				previous history of significant non-compliance to medical treatment.
13. Specific Diagnostic Inclusion
				Criteria:
a) End-stage fibrotic lung disease
				unresponsive to alternative therapy with FVC <65% of predicted.
b) End-stage obstructive lung disease with
				FVC <25% of predicted.
c)
				End-stage pulmonary hypertension, either primary or secondary without
				significant right heart dysfunction, unless heart-lung transplant planned
d) Cystic fibrosis with FVC
				<40% and FEV1 <30% of predicted.
e) Bronchiectasis.
f) Bronchopulmonary dysplasia.
g) Obliterative bronchiolitis.
14. Facility is approved for lung
				transplants by Medicaid.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 4 - Organ Transplants › Rule 23-202-4.18 - Small Bowel Transplant

Current through June 25, 2024
A. Prior
				authorization is required.
B.
				Medicaid covers small bowel transplants meeting the following criteria for
				small bowel (or intestinal) transplantation, whether performed as a solitary
				procedure (SBT); or performed in conjunction with liver (SB/LT); or with
				stomach, duodenum, and pancreas, with or without liver (SB/MVT)
				transplantation:
1. The loss or absence of
				sufficient absorptive capacity of the intestinal tract to support life;
				and
2. The demonstrated failure of
				total parenteral nutrition (TPN).