Utilization Review of Availability of Hospital Resources and Medical Services

Miss. Code Ann. tit. 41, ch. 83
in effect

Miss. Code Ann. § 41-83-1 Definitions.

As used in this chapter, the following terms shall be defined as follows: “Utilization review” means a system for reviewing the appropriate and efficient allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients as to necessity for the purpose of determining whether such service should be covered or provided by an insurer, plan or other entity. “Private review agent” means a nonhospital-affiliated person or entity performing utilization review on behalf of: An employer or employees in the State of Mississippi; or A third party that provides or administers hospital and medical benefits to citizens of this state, including: a health maintenance organization issued a certificate of authority under and by virtue of the laws of the State of Mississippi; or a health insurer, nonprofit health service plan, health insurance service organization, or preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state. “Utilization review plan” means a description of the utilization review procedures of a private review agent. “Department” means the Mississippi State Department of Health. “Certificate” means a certificate of registration granted by the Mississippi State Department of Health to a private review agent.

Miss. Code Ann. § 41-83-3 Certificate requirement for utilization review; nontransferability; disclosure to public.

A private review agent who approves or denies payment or who recommends approval or denial of payment for hospital or medical services or whose review results in approval or denial of payment for hospital or medical services on a case by case basis, may not conduct utilization review in this state unless the Mississippi State Department of Health has granted the private review agent a certificate. The Mississippi State Department of Health shall issue a certificate to an applicant that has met all the requirements of this chapter and all applicable regulations of the department. A certificate issued under this chapter is not transferable. The State Department of Health shall adopt regulations to implement the provisions of this chapter. Any information required by the department with respect to customers or patients shall be held in confidence and not disclosed to the public.

Miss. Code Ann. § 41-83-5 Certificate requirement for general in-house utilization review; exemptions.

No certificate is required for those private review agents conducting general in-house utilization review for hospitals, home health agencies, preferred provider organizations or other managed care entities, clinics, private physician offices or any other health facility or entity, so long as the review does not result in the approval or denial of payment for hospital or medical services for a particular case. Such general in-house utilization review is completely exempt from the provisions of this chapter.

Miss. Code Ann. § 41-83-7 Application for certificate; fees.

An applicant for a certificate shall: Submit an application to the department; and Pay to the department the application fee established by the department through regulation. The application shall: Be on a form and accompanied by any supporting documentation that the department requires; and Be signed and verified by the applicant. The application fee required under this section shall be sufficient to pay for the administrative cost of the certification program and any other cost associated with carrying out the provisions of this chapter.

Miss. Code Ann. § 41-83-9 Submission of information in conjunction with application.

In conjunction with the application, the private review agent shall submit information that the department requires including: A utilization review plan that includes a description of review criteria, standards and procedures to be used in evaluating proposed or delivered hospital and medical care and the provisions by which patients, physicians or hospitals may seek reconsideration or appeal of adverse decisions by the private review agent; The type and qualifications of the personnel either employed or under contract to perform the utilization review; The procedures and policies to insure that a representative of the private review agent is reasonably accessible to patients and providers at all times in this state; The policies and procedures to insure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed; A copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan; and A list of the third party payors for which the private review agent is performing utilization review in this state.

Miss. Code Ann. § 41-83-11 Expiration date of certificate; renewal; fees.

A certificate expires on the second anniversary of its effective date unless the certificate is renewed for a two-year term as provided in this section. Before the certificate expires, a certificate may be renewed for an additional two-year term if the applicant: Otherwise is entitled to the certificate; Pays the department the renewal fee set by the department through regulation; and Submits to the department a renewal application on the form that the department requires and satisfactory evidence of compliance with any requirement of this chapter for certificate renewal.

Miss. Code Ann. § 41-83-13 Grounds for denial or revocation of certificate; time to supply additional information; hearing.

The department shall deny a certificate to any applicant if, upon review of the application, the department finds that the applicant proposing to conduct utilization review does not: Have available the services of a physician to carry out its utilization review activities; Meet any applicable regulations the department adopted under this chapter relating to the qualifications of private review agents or the performance of utilization review; and Provide assurances satisfactory to the department that the procedure and policies of the private review agent will protect the confidentiality of medical records and the private review agent will be reasonably accessible to patients and providers for five (5) working days a week during normal business hours in this state. The department may revoke or deny a certificate if the holder does not comply with the performance assurances under this section, violates any provision of this chapter, or violates any regulation adopted pursuant to this chapter. Before denying or revoking a certificate under this section, the department shall provide the applicant or certificate holder with reasonable time to supply additional information demonstrating compliance with the requirements of this chapter and the opportunity to request a hearing. If an applicant or certificate holder requests a hearing, the department shall send a hearing notice and conduct a hearing in accordance with the Mississippi Administrative Procedure Law, Section 25-43-17, Mississippi Code of 1972.

Miss. Code Ann. § 41-83-15 Reporting requirements to evaluate and determine compliance.

The department shall establish reporting requirements to: Evaluate the effectiveness of private review agents; and Determine if the utilization review programs are in compliance with the provisions of this section and applicable regulations.

Miss. Code Ann. § 41-83-17 Disclosure or publication of information; consent or authorization; court order.

A private review agent may not disclose or publish individual medical records or any other confidential medical information obtained in the performance of utilization review activities without the patient’s authorization or an order of a county, circuit or chancery court of Mississippi or a U.S. district court. Provided, however, that nothing in this chapter shall prohibit private review agents from providing information to a third party with whom the private review agent is under contract or acting on behalf of.

Miss. Code Ann. § 41-83-19 Penalties for violations.

A person who violates any provision of this chapter or any regulation adopted under this chapter is guilty of a misdemeanor and on conviction is subject to a penalty not exceeding One Thousand Dollars ($1,000.00).

Miss. Code Ann. § 41-83-21 Certification of need of immediate hospital care; prima facie evidence.

Notwithstanding language to the contrary elsewhere contained herein, if a licensed physician certifies in writing to an insurer within seventy-two (72) hours of an admission that the insured person admitted was in need of immediate hospital care, such shall constitute a prima facie case of the medical necessity of the admission. To overcome this, the entity requesting the utilization review and/or the private review agent must show by clear and convincing evidence that the admitted person was not in need of immediate hospital care.

Miss. Code Ann. § 41-83-23 Judicial review; other remedies.

Any person aggrieved by a final decision of the department or a private review agent in a contested case under this chapter shall have the right of judicial appeal to the chancery court of the county of the residence of the aggrieved person. Notwithstanding any provision of this chapter, the insured shall have the express right to pursue any legal remedies he may have in a court of competent jurisdiction.

Miss. Code Ann. § 41-83-25 Health insurance plans; certificate requirement; contract with private review agent; reimbursement under policy where medical necessity in dispute.

Every health insurance plan proposing to issue or deliver a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of those benefits shall: Have a certificate in accordance with this chapter; or Contract with a private review agent who has a certificate in accordance with this chapter. Notwithstanding any other provisions of this chapter, for claims where the medical necessity of the provision of a covered benefit is disputed, a health service plan that does not meet the requirements of subsection (1) of this section shall pay any person or hospital entitled to reimbursement under the policy or contract.

Miss. Code Ann. § 41-83-27 Other health insurance policies; certificate requirement; contract with private review agent; reimbursement under policy where medical necessity in dispute.

Every insurer proposing to issue or deliver a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of such benefits shall: Have a certificate in accordance with this chapter; or Contract with a private review agent that has a certificate in accordance with this chapter. Notwithstanding any provision of this chapter, for claims where the medical necessity of the provision of a covered benefit is disputed, an insurer that does not meet the requirements of subsection (1) of this section shall pay any person or hospital entitled to reimbursement under the policy or contract.

Miss. Code Ann. § 41-83-29 Group or blanket health insurance policies; certificate requirement; contract with private review agent.

Any health insurer proposing to issue or deliver in this state a group or blanket health insurance policy or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of such benefits shall: Have a certificate in accordance with this chapter; or Contract with a private review agent that has a certificate in accordance with this chapter.

Miss. Code Ann. § 41-83-31 Adverse determination to patient or health-care provider; discussion of reasons; denial of third party reimbursement or precertification; evaluation by trained specialist.

Any program of utilization review with regard to hospital, medical or other health-care services provided in this state shall comply with the following: No determination adverse to a patient or to any affected health-care provider shall be made on any question relating to the necessity or justification for any form of hospital, medical or other health-care services without prior evaluation and concurrence in the adverse determination by a physician licensed to practice in Mississippi. The physician who made the adverse determination shall discuss the reasons for any adverse determination with the affected health-care provider, if the provider so requests. The physician shall comply with this request within fourteen (14) calendar days of being notified of a request. Adverse determination by a physician shall not be grounds for any disciplinary action against the physician by the State Board of Medical Licensure. Any determination regarding hospital, medical or other health-care services rendered or to be rendered to a patient which may result in a denial of third-party reimbursement or a denial of precertification for that service shall include the evaluation, findings and concurrence of a physician trained in the relevant specialty or subspecialty, if requested by the patient’s physician, to make a final determination that care rendered or to be rendered was, is, or may be medically inappropriate. The requirement in this section that the physician who makes the evaluation and concurrence in the adverse determination must be licensed to practice in Mississippi shall not apply to the Comprehensive Health Insurance Risk Pool Association or its policyholders and shall not apply to any utilization review company which reviews fewer than ten (10) persons residing in the State of Mississippi.

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