23 Miss. Code. R. 213-3.5 - Prior Authorization/Pre-certification

A. Medicaid requires prior authorization/precertification of certain outpatient therapy services. Prior authorization/precertification for therapy services is conducted through the Utilization Management and Quality Improvement Organization (UM/QIO) Failure to obtain prior authorization/precertification will result in denial of payment to the providers billing for services.

B. Prior Authorization/Pre-certification for outpatient therapy services is only required for certain procedure codes when the services fall into one (1) of the following categories:

1. Therapy services provided to beneficiaries, adult and/or children in individual therapist offices or in therapy clinics,

2. Therapy services provided to beneficiaries, adult and/or children in the outpatient department of hospitals,

3. Therapy services provided to beneficiaries, adult and/or children in physician offices/clinics,

4. Therapy services provided to beneficiaries in nursing facilities,

5. Therapy services covered under regular benefits and provided to beneficiaries also enrolled in a Home and Community-Based Services (HCBS) waiver program,

6. Therapy services provided to beneficiaries covered under both Medicare and Medicaid if Medicare benefits have been exhausted,

7. Therapy services provided to beneficiaries under age twenty-one (21) through the following providers: Rural Health Clinics (RHC), Federally Qualified Health Centers (FQHC), and State Department of Health, or

8. Therapy services billed by school providers.

C. Prior Authorization/Precertification is not required, regardless of the procedure codes used, when the services fall into one (1) of the following categories:

1. Therapy services provided to beneficiaries in an ICF/MR,

2. Therapy services provided to beneficiaries in a Private Nursing Facility for the Severely Disabled (PNFSD),

3. Therapy services provided to beneficiaries enrolled in a hospice program, or

4. Therapy services provided to beneficiaries covered under both Medicare and Medicaid if Medicare benefits have not been exhausted.

D. Processes related to certification and recertification of therapy services must be handled in accordance with the procedures set forth by the UM/QIO.

Notes

23 Miss. Code. R. 213-3.5

Miss. Code Ann. § 43-13-121

Amended 11/1/2021