19 Miss. Code. R. 3-15.21
This EXTERNAL REVIEW REQUEST FORM must be filed with Mississippi Insurance Department within FOUR (4) MONTHS after receipt from your insurer of a denial of payment on a claim or request for coverage of a health care service or treatment.
WHAT TO SEND AND WHERE TO SEND IT
PLEASE CHECK BELOW (NOTE: YOUR REQUEST WILL NOT BE ACCEPTED FOR FULL REVIEW UNLESS ALL FOUR (4) ITEMS BELOW ARE INCLUDED*)
**You may make a request for external review without exhausting all internal review procedures under certain circumstances. You should contact the Office of the Insurance Commissioner, Mississippi Insurance Department, Attn: Life and Health Actuarial Division, P.O. Box 79, Jackson, MS 39205, Phone: (601) 359-3569.
*Call the Insurance Department at (601) 359-3569 if you need help in completing this application or if you do not have one or more of the above items and would like information on alternative ways to complete your request for external review.
If you are requesting a standard external review, send all paperwork to: Mississippi Insurance Department, Attn: Life and Health Actuarial Division, P.O. Box 79, Jackson, MS 39205
If you are requesting an expedited external review, call the Insurance Department before sending your paperwork, and you will receive instructions on the quickest way to submit the application and supporting information.
CERTIFICATION OF TREATING HEALTH CARE PROVIDER FOR EXPEDITED CONSIDERATION OF A PATIENT'S EXTERNAL REVIEW APPEAL
NOTE TO THE TREATING HEALTH CARE PROVIDER
Patients can request an external review when a health carrier has denied a health care service or course of treatment on the basis of a utilization review determination that the requested health care service or course of treatment does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested. The Mississippi Insurance Department oversees external appeals. The standard external review process can take up to 45 days from the date the patient's request for external review is received by our department. Expedited external review is available only if the patient's treating health care provider certifies that adherence to the time frame for the standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function. An expedited external review must be completed at most within 72 hours. This form is for the purpose of providing the certification necessary to trigger expedited review.
PHYSICIAN CERTIFICATION
EXPERIMENTAL/INVESTIGATIONAL DENIALS
(To Be Completed by Treating Physician)
I hereby certify that I am the treating physician for__________________(covered person's name) and that I have requested the authorization for a drug, device, procedure or therapy denied for coverage due to the insurance company's determination that the proposed therapy is experimental and/or investigational. I understand that in order for the covered person to obtain the right to an external review of this denial, as treating physician I must certify that the covered person's medical condition meets certain requirements:
In my medical opinion as the Insured's treating physician, I hereby certify to the following:
(Please check all that apply) (NOTE: Requirements #1 - #3 below must all apply for the covered person to qualify for an external review).
[] 1) The covered person has a terminal medical condition, life threatening condition, or a seriously debilitating condition.
[] 2) The covered person has a condition that qualifies under one or more of the following:
[please indicate which description(s) apply]:
[] Standard health care services or treatments have not been effective in improving the covered person's condition;
[] Standard health care services or treatments are not medically appropriate for the covered person; or
[] There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the requested or recommended health care service or treatment.
[] 3) The health care service or treatment I have recommended and which has been denied, in my medical opinion, is likely to be more beneficial to the covered person than any available standard health care services or treatments.
[] 4) The health care service or treatment recommended would be significantly less effective if not promptly initiated.
Explain:_____________________________________________________________________________________
_____________________________________________________________________________________________
[] [] 5) It is my medical opinion based on scientifically valid studies using accepted protocols that the health care service or treatment requested by the covered person and which has been denied is likely to be more beneficial to the covered person than any available standard health care services or treatments. Explain:
____________________________________________________________________________________
____________________________________________________________________________________Please provide a description of the recommended or requested health care service or treatment that is the subject of the denial. (Attach additional sheets as necessary)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________ ____________________________
Physician's Signature Date
19 Miss. Code. R. 3-15.21