19 Miss. Code. R. 3-19.06 - Application for Certification

(1) 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 Department of Insurance has granted the private review agent a certificate. Any valid and active certificate issued by the Mississippi Department of Health prior to July 1, 2024, shall be honored by the Mississippi Department of Insurance until such time as the expiration or revocation of said certificate.

(2) The Mississippi Insurance Department shall issue a certificate to any applicant that has met all the requirements and all applicable regulations of the Department.

(3) A certificate is not transferable. When there is a change of ownership of the Certified Organization, a new application will be required and a new number will be issued.

(4) Any information required by the Department with respect to customers, patients or utilization review procedures of a private review agent shall be held in confidence and not disclosed to the public.

(5) A Private Review Agent applying for a certificate shall submit the following documentation to the Department:

a. A completed application, signed and verified by the applicant;

b. A fee of $1,500.00, made payable to the Mississippi Insurance Department, either by business check, money order, or by electronic means; and

c. A utilization review plan which shall include all of the following components used by the private review agent to approve or deny payment or recommend approval or denial of payment in advance for proposed or delivered inpatient or outpatient care or retrospectively approve or deny under certain circumstances:

1) Elements of review for:

i) Preadmission

ii) Admission

iii) Preauthorization

iv) Second Surgical Opinion

2) Discharge Planning

i) Concurrent Review

ii) Retrospective Review

iii) Readmission Review

3) Procedures for review, including:

i) Any form used during the review process;

ii) Time frames that shall be met during the review; and

iii) A written protocol describing every aspect of the review process;

iv) A description and examples of review criteria to be used for the review;

v) The provisions, procedures, and time frames by which patients, physicians, and hospitals may seek reconsideration or appeal of adverse decisions by the private review agent, including:

(a) A written protocol describing the appeals procedure;

(b) Any form which shall be completed during the appeals procedure;

(c) Time frames that shall be met during the appeal procedure; and

(d) The names and qualifications of personnel making final appeal determinations;

(i) The number, type, and qualification or qualifications of the personnel either employed or under contract to perform the utilization review;

(ii) The policies and procedures to ensure that a representative of the private review agent is accessible to patients and providers five (5) days a week during normal business hours in this state, 9 A.M. to 5 P.M.; and that a free telephone number be provided with adequate lines available and staffed. The procedure for handling after-hours inquiries shall be specified.

(iii) The policies and procedures to ensure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed;

(iv) A copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan; and

(v) A list (names and addresses) of the third party payors for which the private review agent is performing utilization review in this state.

vi) Compliance with statutory prior authorization requirements as set forth in Miss. Code Ann. §§ 83-5-901 through 83-5-937.

Notes

19 Miss. Code. R. 3-19.06

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

Adopted 1/1/2025