20 Miss. Code R. § 2-II
For the purpose of this fee schedule the following activities have been defined:
Authorization. An authorization is an approval of medical services by a carrier/payer/employer, usually prior to service being rendered.
Case Management. The clinical and administrative process in which timely, individualized, and cost effective medical rehabilitation services are implemented, coordinated, and evaluated, by a nurse, other case manager, or other utilization reviewer employed by the payer, on an ongoing basis for patients who have sustained an injury or illness. Use of case management is optional in Mississippi. Use state-specific code 9936M for a conference with workers' compensation medical case manager/claims manager.
Clinical Peer. A health professional that holds an unrestricted medical or equivalent license and is qualified to practice in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review. Generally, as a peer in a similar specialty, the individual must be in the same profession (i.e., the same licensure category as the ordering provider).
Clinical Rationale. A statement or other documentation that taken together provides additional clarification of the clinical basis for a non-certification determination. The clinical rationale should relate the non-certification determination to the worker's condition or treatment plan, and must include a detailed basis for denial or non-certification of the proposed treatment so as to give the provider or patient a sufficient basis for a decision to pursue an appeal. Clinical rationale must include specific reference to any applicable provisions of the Mississippi Workers' Compensation Medical Fee Schedule which allegedly support the determination of the reviewer, or a statement attesting to the fact that no such provision(s) exists in the Fee Schedule.
Concurrent Review. Certification or Authorization review conducted during a worker's hospital stay or course of treatment, sometimes called continued stay review.
Discharge Planning. The process of assessing a patient's need for medically appropriate treatment after hospitalization including plans for an appropriate and timely discharge
* Expedited Appeal. An expedited appeal is a request to reconsider a prior determination not to certify imminent or ongoing services, an admission, an extension of stay, or other medical services of an emergency, imminent, or ongoing nature.
First Level Clinical Review. Review conducted by a registered nurse, nurse case manager, or other appropriate licensed or certified health professional. First level clinical review staff may approve requests for admissions, procedures, and services that meet the standard of medical necessity as defined elsewhere in the Fee Schedule, but must refer requests that do not meet this medical necessity standard, in their opinion, to second level clinical peer reviewers for approval or denial.
Notification. Correspondence transmitted by mail, telephone, facsimile, email, and/or other reliable electronic means.
Peer Review. A review of any issue related to a claim as requested by another party. (Not usually requested by the provider.)
Precertification. The review and assessment of proposed medical treatment or services before they occur to determine if such treatment or services meet the definition of medical necessity as set forth elsewhere in this Fee Schedule. The appropriateness of the site or level of care is assessed along with the duration and timing of the proposed services.
Provider. A licensed health care facility, program, agency, or health professional that delivers health care services.
Retrospective Review. Authorization review conducted after services have been provided to the worker.
Second Level Clinical Review. Peer review conducted by appropriate clinical peers when the First Level Clinical Reviewer is unable to determine whether a request for an admission, procedure, or service satisfies the standard of medical necessity as defined elsewhere in this Fee Schedule. A decision to deny, or not certify, proposed treatment or services, must be supported by the express written evaluation, findings and concurrence of a physician licensed to practice medicine in the State of Mississippi and properly trained in the same specialty as the requesting provider.
Standard Appeal. A request by or on behalf of the patient or provider to reconsider a prior decision by the payer or its utilization review agent to deny proposed medical treatment or service, including but not limited to, a determination not to certify an admission, extension of stay, or other health care service.
Third Level Clinical Review. Medical necessity review conducted by appropriate clinical peers who were not involved in the first or second level review when a decision not to certify a requested admission, procedure, or service has been appealed. The third level peer reviewer must be in the same or like specialty as the requesting provider. A decision to deny, or not certify, proposed treatment or services, must be supported by the express written evaluation, findings and concurrence of a physician licensed to practice medicine in the State of Mississippi and properly trained in the same specialty as the requesting provider.
Utilization Reviewer. An entity, organization, or representative/person performing authorization/pre-certification activities or services on behalf of an employer, payer or third-party claims administrator.
Variance. A deviation from a specific standard.
20 Miss. Code. R. § 2-II