23 Miss. Code. R. 302-2.5 - Provider Selection
A. The beneficiary
has ten (10) days to choose his/her Beneficiary Health Management (BHM)
designated physician and/or pharmacy provider(s) from the date of receipt of
the notification letter.
B. The
Division of Medicaid will designate a BHM physician and/or pharmacy provider
for the beneficiary if the beneficiary does not specify a provider within the
ten (10) day time-frame.
C.
Beneficiaries are required to specify one (1) physician and/or one (1) pharmacy
and up to three (3) physician specialists, if requested, for his/her medical
and/or pharmacy services while in the Beneficiary Health Management (BHM)
program.
D. The beneficiary may
request a change in his/her BHM physician and/or pharmacy provider if any of
the following occur:
1. Change in physical
address of the beneficiary or a provider,
2. Death, retirement, or closing of the
specified physician, pharmacy and/or specialist,
3. Change in primary diagnosis which requires
a different specialist, or
4. The
BHM physician and/or pharmacy provider disenrolls or loses eligibility to
participate in the Mississippi Medicaid Program.
E. The BHM physician or specialist may refer
the beneficiary to another provider for consultation by submitting the BHM
Referral Form to the Division of Medicaid, Office of Program Integrity, or
designee.
1. Prior approval from the Division
of Medicaid or designee is required before the beneficiary can be seen by the
referring physician.
2. Emergency
situations are excluded from this requirement.
3. The referral may cover one (1) or multiple
visits as long as those visits are part of the consulting physician's plan of
care and are medically necessary.
4. A referral is limited to one (1) year from
the date of approval.
F. The Division of Medicaid will lock-in
beneficiaries to only one (1) pharmacy when one (1) of the following criteria
is met:
1. The beneficiary has one (1) or
more of the following:
a) Received services
from four (4) or more prescribers and/or four (4) or more pharmacies relative
to controlled substances in the past six (6) months, including emergency
department visits,
b) A history of
substance use disorder within the past twelve (12) months,
c) A diagnosis of drug abuse or narcotic
poisoning within the past twelve (12) months, or
d) Utilizes cash payments to purchase
controlled substances.
2. When any written prescription is stolen,
forged or altered,
3. When the
Division of Medicaid has received a proven report of fraud, waste and/or abuse
from one (1) or more of the following:
a)
Prescriber,
b) Pharmacy,
c) Any medical provider, and/or
d) Law enforcement entity.
Notes
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