19 Miss. Code. R. 3-19.08 - Denial or Revocation of Certification and Penalty

(1) The Commissioner shall deny a certificate to an applicant if the Department finds that the applicant does not:

a. Have available the services of a sufficient number of registered nurses, that are supervised by appropriate physicians to efficiently carry out its utilization review activities;

i. Meet any applicable provisions of these rules and regulations relating to the qualifications of private review agents or the performance of utilization review the Department adopts relating to the qualifications of private review agents or the performance of utilization review;

ii. Have policies and procedures which protect the confidentiality of medical records in accordance with applicable state and federal laws;

iii. Make itself accessible to patients and providers five (5) working days a week during normal business hours in this state, or

iv. Does not comply with prior authorization standards as provided in Miss. Code Ann. §§ 83-5-901 through 83-5-937.

(2) The Commissioner may revoke the certification of a private review agent if the Department finds that the agent:

a. Does not comply with performance assurances;

b. Violates any provision of these rules and regulations;

c. Fails to substantially meet the standards and qualifications adopted by the Commissioner;

d. Does not comply with prior authorization standards as provided in Miss. Code Ann. §§ 83-5-901 through 83-5-937; or

e. Fails to comply with the regulations adopted by the Department.

(3) Before denying or revoking a certificate, the Commissioner shall comply with the process for Administrative Hearings as provided in 19 Miss. Admin. Code, Part 1, Rule 15.08 and Rule 15.09, "Rules of Practice and Procedure before the Mississippi Insurance Department and State Fire Marshal's Office".

(4) 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. It is provided, however, that nothing in these regulations shall prohibit private review agents from providing information to the third party with whom the private review agent is under contract or acting on behalf of.

Notes

19 Miss. Code. R. 3-19.08

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

Adopted 1/1/2025