23 Miss. Code. R. 302-2.1 - Authority and Purpose

A. The Division of Medicaid defines Beneficiary Health Management (BHM) as the program implemented by the Division of Medicaid to:

1. Closely monitor program usage and to identify beneficiaries who may be potentially over utilizing or misusing their Medicaid services and benefits.

2. Restrict beneficiaries whose utilization of medical and/or pharmacy services is documented at a frequency or amount that is not medically necessary.

3. Prevent beneficiaries from obtaining non-medically necessary quantities of prescribed drugs through multiple visits to physicians and pharmacies.

B. The Division of Medicaid will lock-in beneficiaries for twelve (12) consecutive months whose utilization of medical and/or pharmacy services is documented as being excessive, as determined in accordance with utilization guidelines established by the Division of Medicaid, to specific providers in order to monitor services received and reduce unnecessary or inappropriate utilization.

C. The Division of Medicaid requires a beneficiary to designate a physician and/or a pharmacy of choice when the beneficiary's medical record indicates utilization is excessive or inappropriate with reference to medical need, and in accordance with the BHM program, to:

1. Promote quality health care,

2. Promote coordination of care and ensure appropriate access for beneficiaries at high risk of overdose,

3. Provide continuity of medical care,

4. Prevent harmful practices such as duplication of medical services, drug interaction, and possible drug abuse,

5. Prevent misuse or excessive utilization of beneficiary's Medicaid benefits,

6. Provide education and monitoring to deter misuse and/or excess utilization, and

7. Assure beneficiaries are receiving only health care services which are medically necessary as defined in Miss. Admin. Code Part 200, Rule 5.1.

Notes

23 Miss. Code. R. 302-2.1

42 C.F.R. § 431.54; Miss. Code Ann. §§ 43-13-117, 43-13-121

Adopted 2/1/2019