19 Miss. Code. R. 3-15.06 - Exhaustion of Internal Grievance Process

A.

1. Except as provided in subsection B, a request for an external review pursuant to Rule 15.07, Rule 15.08 or Rule 15.09 of this Regulation shall not be made until the covered person has exhausted the health carrier's internal grievance process.

2. A covered person shall be considered to have exhausted the health carrier's internal grievance process for purposes of this section, if the covered person or the covered person's authorized representative:

a. Has filed a grievance involving an adverse determination with the health carrier; and

b. Except to the extent the covered person or the covered person's authorized representative requested or agreed to a delay, has not received a written decision on the grievance from the health carrier within thirty (30) days following the date the covered person or the covered person's authorized representative filed the grievance with the health carrier.

3. Notwithstanding paragraph (2), a covered person or the covered person's authorized representative may not make a request for an external review of an adverse determination involving a retrospective review determination until the covered person has exhausted the health carrier's internal grievance process.

B.

1.

a. At the same time a covered person or the covered person's authorized representative files a request for an expedited review of a grievance involving an adverse determination, covered person or the covered person's authorized representative may file a request for an expedited external review of the adverse determination:

i. Under Rule 15.08 of this Regulation if the covered person has a medical condition where the timeframe for completion of an expedited review of the grievance involving an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; or

ii. Under Rule 15.09 of this Regulation if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated.

b. Upon receipt of a request for an expedited external review under subparagraph (a) of this paragraph, the independent review organization conducting the external review in accordance with the provisions of Rule 15.08 or Rule 15.09 of this Regulation shall determine whether the covered person shall be required to complete the expedited review process before it conducts the expedited external review.

c. Upon a determination made pursuant to subparagraph (b) of this paragraph that the covered person must first complete the expedited grievance review process, the independent review organization immediately shall notify the covered person and, if applicable, the covered person's authorized representative of this determination and that it will not proceed with the expedited external review set forth in Rule 15.08 of this Regulation until completion of the expedited grievance review process and the covered person's grievance at the completion of the expedited grievance review process remains unresolved.

2. A request for an external review of an adverse determination may be made before the covered person has exhausted the heath carrier's internal grievance procedures whenever the health carrier agrees to waive the exhaustion requirement.

C. If the requirement to exhaust the health carrier's internal grievance procedures is waived under subsection B(2), the covered person or the covered person's authorized representative may file a request in writing for a standard external review as set forth in Rule 15.07 or Rule 15.09 of this Regulation.

Notes

19 Miss. Code. R. 3-15.06

Miss. Code Ann. § 83-5-1 (Rev. 2011); Public Law 111-148 -Mar. 23, 2010 (Patient Protection and Affordable Care Act)

Adopted 4/15/2015