19 Miss. Code. R. 3-19.04 - Applicability and Scope

This Regulation shall apply to every health insurance issuer and all health benefit plans, as both terms are defined in Miss. Code Ann. § 83-9-6.3, and all private review agents and utilization review plans, as both terms are defined in Miss. Code Ann. § 41-83-1, with the exception of employee or employer self-insured health benefit plans under the federal Employee Retirement Income Security Act of 1974 or health care provided pursuant to the Workers' Compensation Act. This act does not diminish the duties and responsibilities under other federal or state law or rules promulgated under those laws applicable to a health insurer, health insurance issuer, health benefit plan, private review agent or utilization review plan, including, but not limited to, the requirement of a certificate in accordance with Miss. Code Ann § 41-83-3.

For simplification, when the term "health insurance issuer" is used alone in these Regulations, the term also includes health benefit plans, private review agents and utilization review plans unless otherwise explicitly stated.

(1) In the State of Mississippi, every health insurance plan or 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 those benefits; every 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:

a. Have a certificate in accordance with these regulations;

b. Contract with a private review agent that has a certificate in accordance with these regulations.

(2) Notwithstanding any provisions of these regulations, for claims where medical necessity of the provision of a covered benefit is disputed, an insurer that does not meet the requirements of this section shall pay any person or hospital entitled to reimbursement under the policy or contract.

Notes

19 Miss. Code. R. 3-19.04

Miss. Code Ann. § 41-83-1, et seq. (Rev. 2023); Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Adopted 1/1/2025