19 Miss. Code. R. 3-19.11 - Computation of Time
(1) Utilization
review of prior authorizations in nonurgent circumstances. If a
health insurance issuer requires prior authorization of a health care service,
the health insurance issuer must make an approval or adverse determination and
notify the enrollee, the enrollee's health care professional, and the
enrollee's health care provider of the approval or adverse determination as
expeditiously as the enrollee's condition requires but no later than seven (7)
calendar days after obtaining all necessary information to make the approval or
adverse determination, unless a longer minimum time frame is required under
federal law for the health insurance issuer and the health care service at
issue. As used in this section, "necessary information" includes the results of
any face-to-face clinical evaluation, second opinion or other clinical
information that is directly applicable to the requested service that may be
required. Notwithstanding the foregoing provisions of this section, health
insurance issuers must comply with the requirements of Miss. Code
Ann. §
83-9-6.3 to respond by two (2)
business days for prior authorization requests for pharmaceutical services and
products.
(2) Utilization review of
prior authorizations in urgent circumstances.
a. If requested by a treating health care
provider or health care professional for an enrollee, a health insurance issuer
must render an approval or adverse determination concerning urgent health care
services and notify the enrollee, the enrollee's health care professional and
the enrollee's health care provider of that approval or adverse determination
as expeditiously as the enrollee's condition requires but no later than
forty-eight (48) hours after receiving all information needed to complete the
review of the requested health care services, unless a longer minimum time
frame is required under federal law for the health insurance issuer and the
urgent health care service at issue.
b. To facilitate the rendering of a prior
authorization determination in conformance with this section, a health
insurance issuer must establish a mechanism to ensure health care professionals
have access to appropriately trained and licensed clinical personnel who have
access to physicians for consultation, designated by the plan to make such
determinations for prior authorization concerning urgent care
services.
(3)
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 for emergency services, 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.
(4)
Notwithstanding the foregoing provisions of this Rule, health insurance issuers
must comply with the requirements of Miss. Code Ann. §
83-9-6.2 to respond by two (2)
business days for prior authorization requests for pharmaceutical services and
products.
Notes
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No prior version found.