Section 20-2-III - STANDARDSPayers, providers and their utilization review organizations or programs or agents are required to meet the following standards:
A. The payer's utilization reviewer or agent must comply with the licensing and certification requirements of MCA § 41-83-1 et seq. (Rev. 2005), as amended, and any regulations adopted pursuant thereto by the State Department of Health or the State Board of Medical Licensure, and shall have utilization review personnel, agents or representatives who are properly qualified, trained, supervised, and supported by explicit clinical review criteria and review procedures. In no event shall proposed treatment or services be denied except in accordance with the express provisions stated elsewhere in these Rules and in accordance with MCA §41-83- 31 (Rev. 2009). B. The first level review is performed if the claims adjuster or manager has not already approved the treatment in question, and is performed by individuals who are health care professionals, who possess a current and valid professional license, and who have been trained in the principles and procedures of utilization review. C. The first level reviewers are required to be supported by a doctor of medicine who has an unrestricted license to practice medicine, and in cases where treatment is being denied or withheld by a utilization reviewer, this determination must be supported in writing by a physician licensed in Mississippi and trained in the relevant specialty or sub-specialty, as previously set forth in these Rules. D. The second and third level review is performed by clinical peers who hold a current, unrestricted Mississippi license to practice in the same or like specialty as the treating physician whose recommendation is under review, and are oriented in the principles and procedures of utilization review. The second level review shall be conducted for all cases where a clinical determination to certify has not already been made by the payer or payer's agent, and the determination of medical necessity cannot be made by first level clinical reviewers. Second and third level clinical reviewers shall be available within one (1) business day by telephone or other electronic means to discuss the determination with the attending physicians or other ordering providers. In the event more information is required before a determination can be rendered by a second or third level reviewer, the attending/ordering provider must be notified immediately of the delay and given a specific time frame for determination, and a specific explanation of the additional information needed. A requesting provider shall not be required to participate in further discussions where the payer or its agents have unilaterally scheduled such a conference. Further, a request for treatment or service may not be denied solely on grounds the requesting provider fails to participate in a conference which has been unilaterally scheduled by the payer or their agent. Follow-up conferences must be arranged by joint agreement. E. The payer's utilization reviewer shall maintain all licensing applications, certificates, and other supporting information, including any and all reports, data, studies, etc., along with written policies and procedures for the effective management of its authorization/pre-certification activities, which shall be made available to the provider, or the Commission, upon request.F. The payer maintains the responsibility for the oversight of the delegated functions if the payer delegates authorization/pre-certification responsibility to a vendor. The vendor or organization to which the function is being delegated must be currently certified by the Mississippi Board of Health, Division of Licensure and Certification to perform utilization management in the State of Mississippi. A copy of the license or certification held by the utilization review agent shall be furnished to the provider, or to the Commission, upon request. The payer who has another entity perform authorization/pre-certification functions or activities on its behalf maintains full responsibility for compliance with the rules. G. The payer's utilization reviewer shall maintain a telephone review service that provides access to its review staff at a toll free number from at least 9:00 a.m. to 5:00 p.m. CT each normal business day. There should be an established procedure for receiving or redirecting calls after hours or receiving faxed or electronic requests. Reviews should be conducted during hospitals' and health professionals' reasonable and normal business hours. H. The payer's utilization reviewer shall collect only the information necessary to certify the admission procedure or treatment, length of stay, frequency, and duration of services. The utilization reviewer should have a process to share all clinical and demographic information on individual workers among its various clinical and administrative departments to avoid duplicate requests to providers.I. Providers must submit a request to the payer using the MWCC Request for Authorization/Pre-certification. (A copy of this form is provided in the forms section of this fee schedule.)20 Miss. Code. R. § 2-III