30 Miss. Code. R. 2301-1.59 - BOARD REGULATION NUMBER 59-LICENSURE OF INDIVIDUALS PERFORMING DENTAL UTILIZATION REVIEW
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Purpose: To stipulate Mississippi licensure requirements for individuals performing dental utilization review.
Any program of utilization review with regard to dental care services provided in this State shall comply with the following:
1. No determination adverse to a patient or
to any dental provider shall be made on any question relating to the necessity
or justification for dental care services without prior evaluation and
concurrence in the adverse determination by a dentist licensed to practice in
Mississippi. The reviewing dentist who made the adverse determination shall
discuss the reasons for any adverse determination with the affected dentist
provider, if the provider so requests. The reviewing dentist shall comply with
this request within fourteen (14) calendar days of being notified of a request.
An adverse determination by a reviewing dentist shall not be grounds for any
disciplinary action against the dentist by the Mississippi State Board of
Dental Examiners.
2. Any
determination regarding dental care services rendered or to be rendered to a
patient which may result in a denial of third-party reimbursement or a denial
of pre-certification for that service shall include the evaluation, findings,
and concurrence of a reviewing dentist trained in the relevant specialty or
sub-specialty, if requested by the patient's dentist, to make a final
determination that care rendered or to be rendered was, is, or may be
inappropriate.
3. The requirement
in this section that a reviewing dentist who makes the evaluation and
concurrence in the adverse determination must be licensed to practice in
Mississippi shall not apply to the Comprehensive Health Insurance Risk Pool
Association or its policyholders.
Notes
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