As used in this chapter, the following terms shall be defined as follows: “Utilization review” means a system for reviewing the appropriate and efficient allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients as to necessity for the purpose of determining whether such service […]
A certificate expires on the second anniversary of its effective date unless the certificate is renewed for a two-year term as provided in this section. Before the certificate expires, a certificate may be renewed for an additional two-year term if the applicant: Otherwise is entitled to the certificate; Pays the department the renewal fee set […]
The department shall deny a certificate to any applicant if, upon review of the application, the department finds that the applicant proposing to conduct utilization review does not: Have available the services of a physician to carry out its utilization review activities; Meet any applicable regulations the department adopted under this chapter relating to the […]
The department shall establish reporting requirements to: Evaluate the effectiveness of private review agents; and Determine if the utilization review programs are in compliance with the provisions of this section and applicable regulations.
A private review agent may not disclose or publish individual medical records or any other confidential medical information obtained in the performance of utilization review activities without the patient’s authorization or an order of a county, circuit or chancery court of Mississippi or a U.S. district court. Provided, however, that nothing in this chapter shall […]
A person who violates any provision of this chapter or any regulation adopted under this chapter is guilty of a misdemeanor and on conviction is subject to a penalty not exceeding One Thousand Dollars ($1,000.00).
Notwithstanding language to the contrary elsewhere contained herein, if a licensed physician certifies in writing to an insurer within seventy-two (72) hours of an admission that the insured person admitted was in need of immediate hospital care, such shall constitute a prima facie case of the medical necessity of the admission. To overcome this, the […]
Any person aggrieved by a final decision of the department or a private review agent in a contested case under this chapter shall have the right of judicial appeal to the chancery court of the county of the residence of the aggrieved person. Notwithstanding any provision of this chapter, the insured shall have the express […]
Every health insurance plan proposing to issue or deliver a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of those benefits shall: Have a certificate in accordance with this chapter; or Contract with a private review agent who […]
Every insurer proposing to issue or deliver a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of such benefits shall: Have a certificate in accordance with this chapter; or Contract with a private review agent that has a […]
Any health insurer proposing to issue or deliver in this state a group or blanket health insurance policy or administer a health benefit program which provides for the coverage of hospital and medical benefits and the utilization review of such benefits shall: Have a certificate in accordance with this chapter; or Contract with a private […]
A private review agent who approves or denies payment or who recommends approval or denial of payment for hospital or medical services or whose review results in approval or denial of payment for hospital or medical services on a case by case basis, may not conduct utilization review in this state unless the Mississippi State […]
Any program of utilization review with regard to hospital, medical or other health-care services provided in this state shall comply with the following: No determination adverse to a patient or to any affected health-care provider shall be made on any question relating to the necessity or justification for any form of hospital, medical or other […]
No certificate is required for those private review agents conducting general in-house utilization review for hospitals, home health agencies, preferred provider organizations or other managed care entities, clinics, private physician offices or any other health facility or entity, so long as the review does not result in the approval or denial of payment for hospital […]
An applicant for a certificate shall: Submit an application to the department; and Pay to the department the application fee established by the department through regulation. The application shall: Be on a form and accompanied by any supporting documentation that the department requires; and Be signed and verified by the applicant. The application fee required […]
In conjunction with the application, the private review agent shall submit information that the department requires including: A utilization review plan that includes a description of review criteria, standards and procedures to be used in evaluating proposed or delivered hospital and medical care and the provisions by which patients, physicians or hospitals may seek reconsideration […]
