23 Miss. Code. R. 202-1.18 - Review for Medical Necessity and/or Independent Verification and Validation (IV&V)
A. The Division of
Medicaid defines Review for Medical Necessity and/or Independent Verification
and Validation (IV&V) as the Utilization Management/Quality Improvement
Organization (UM/QIO) or Division of Medicaid, or designee, review of services
of Medicaid beneficiaries in the inpatient setting for including, but not
limited to, the following:
1. Meeting clinical
guidelines for medical necessity. [Refer to Part 200, Rule 5.1 for definition
of medical necessity],
2.
Appropriateness of setting and quality of care,
3. Appropriate lengths of stay and services,
and
4. Correct All Patient Refined
Diagnosis Related Groups (APR-DRG) assignment.
B. The inpatient hospital provider must
submit the requested documentation to the UM/QIO or the Division of Medicaid,
or designee, within the specified time frame in the Notice.
C. Inpatient hospital providers may request
an Administrative Appeal when the provider is dissatisfied with final
administrative decisions of the Division of Medicaid relating to disallowances
as a result of a review for medical necessity or an IV&V decision described
in Miss. Admin. Code Part 202, Rule 1.18.A.
D. Providers must comply with the appeal
provisions in Miss. Admin. Code Part 300, Rule
1.1.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.