Section 20-2-IV - PROCEDURES FOR REVIEW DETERMINATIONSThe following procedures are required for effective review determination.
A. Initial review determinations must be made within two (2) business days of receipt of the treating physician's records and other necessary information on a proposed non-emergency admission or service requiring a review determination. Receipt of necessary information may necessitate a discussion with the attending physician and may involve a completed second level clinical review. In the case of determinations made by a specialist conducting a second level clinical review as defined under the Authorization/Pre-Certification Rules of the Fee Schedule, the two (2) day period begins to run upon the payer's receipt of a completed second opinion review from the second level clinical reviewer. Second level clinical review is not an Employer's Medical Evaluation (EME). In an EME, the employee is examined. In contrast, a second level clinical review as defined under the Fee Schedule does not include an in-person examination of the employee. An EME conducted in lieu of pre-certification is governed by other provisions of the Authorization/Pre-Certification Rules of the Fee Schedule, Miss. Code Ann. Section 71-3-15, and Miss. Work. Comp. Com. General Rule 1.9. In cases where an EME is conducted in lieu of pre-certification, the payer must notify the provider and the injured worker of its election to obtain an EME within the same (2) day period applicable to initial review determinations that begins once the payer has received the necessary information. However, in that instance, collection of the necessary information will not include the opinion of a second level clinical reviewer because no second level clinical reviewer will be used. Rather, the EME is elected in lieu of any further pre-certification. The Mississippi Workers' Compensation Commission Request for Authorization/pre-certification of Medical Treatment form may be used to request authorization/pre-certification. B. When an initial determination is made to certify, notification shall be provided promptly, at least within one (1) business day or before the service is scheduled, whichever first occurs, either by telephone or by written or electronic notification to the provider or facility rendering the service. If an initial determination to certify is provided by telephone, a written notification of the determination shall be provided within two (2) business days thereafter. The written notification shall include the number of days approved, the new total number of days or services approved, and the date of admission or onset of services.C. When a determination is made not to certify, notification to the attending or ordering provider or facility must be provided by telephone or electronic means within one (1) business day followed by a written notification within one (1) business day thereafter. The written notification must include the principal reason/clinical rationale for the determination not to certify, including specific reference to any provision of this Fee Schedule relied upon by the reviewer, and instructions for initiating an appeal and/or reconsideration request.D. The payer or its review agent shall inform the attending physician and/or other ordering provider of their right to initiate an expedited appeal in cases involving emergency or imminent care or admission, or a standard appeal, as the case may permit, of a determination not to certify, and the procedure to do so.1. Expedited appeal-When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring imminent or expedited review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone or by electronic mail or facsimile on an expedited basis within one (1) business day. a. Each private review agent shall provide for prompt and expeditious access to its consulting physician(s) for such appeals.b. Both providers of care and private review agents should attempt to share the maximum information by phone, fax, or otherwise to resolve the expedited appeal (sometimes called a reconsideration request) satisfactorily.c. Expedited appeals, which do not resolve a difference of opinion, may be resubmitted through the standard appeal process, or submitted directly to the Commission's Medical Cost Containment Division as a Request for Resolution of Dispute. A disagreement warranting expedited review or reconsideration does not have to be resubmitted to the payer or utilization review agent through the standard appeal process unless the requesting provider so wishes.2. Standard appeal-A standard appeal will be considered as a request for reconsideration, and notification of the appeal decision given to the provider, not later than twenty (20) calendar days after receiving the required documentation for the appeal.a. An attending physician who has been unsuccessful in an attempt to reverse a determination not to certify treatment or services must be provided the clinical rationale for the determination along with the notification of the appeal decision. 3. Retrospective review-For retrospective review, the review determination shall be based on the medical information available to the attending or ordering provider at the time the medical care was provided, and on any other relevant information regardless of whether the information was available to or considered by the provider at the time the care or service was provided. Retrospective review is not optional or conducted solely at the discretion of the review agent. A request for review and approval of services already provided must be handled by the payer or its utilization reviewer in the same manner any other request for approval of services is handled. a. When there is retrospective determination not to certify an admission, stay, or other service, the attending physician or other ordering provider and hospital or facility shall receive written notification, or notification by facsimile or electronic mail, within twenty (20) calendar days after receiving the request for retrospective review and all necessary and supporting documentation.b. Notification should include the principal reasons for the determination and a statement of the procedure for standard appeal if the determination is adverse to the patient.4. Emergency admissions or surgical procedures-Emergency admissions or surgical procedures must be reported to the payer by the end of the next business day. Retrospective review activities will be performed following emergency admissions, and a continued stay review may be initiated. a. If a licensed physician certifies in writing to the payer or its agent or representative within seventy-two (72) hours of an admission that the injured worker admitted was in need of emergency admission to hospital care, such shall constitute a prima facie case for the medical necessity of the admission. An admission qualifies as an emergency admission if it results from a sudden onset of illness or injury which is manifested by acute symptoms of sufficient severity that the failure to admit to hospital care could reasonably result in (1) serious impairment of bodily function(s), (2) serious or permanent dysfunction of any bodily organ or part or system, (3) permanently placing the person's health in jeopardy, or (4) other serious medical consequence. b. To overcome a prima facie case for emergency admission as established above, the utilization reviewer must demonstrate by clear and convincing evidence that the patient was not in need of an emergency admission. E. Failure of the health care provider to provide necessary information for review, after being specifically requested to do so by the payer or its review agent in detail, may result in denial of certification and/or reimbursement.F. When a payer and provider have completed the authorization/pre-certification appeals process and cannot agree on a resolution to a dispute, either party, or the patient, can appeal to the Cost Containment Division of the Mississippi Workers' Compensation Commission, and should submit this request on the Request for Dispute Resolution Form adopted by the Commission. A request for resolution of a authorization/pre-certification dispute should be filed with the Commission within twenty (20) calendar days following the conclusion of the underlying appeal process provided by the payer or its utilization reviewer. The Commission shall consider and decide a request for resolution of a authorization/pre-certification dispute in accordance with the Dispute Resolution Rules provided elsewhere in this Fee Schedule.G. Failure of a payer or its utilization review agent to timely notify the provider of a decision whether to certify or approve an admission, procedure, service or other treatment shall be deemed to constitute approval by the payer of the requested treatment, and shall obligate the payer to reimburse the provider in accordance with other applicable provisions of this Fee Schedule should the provider elect to proceed with the proposed treatment or service. Timely notification means notification by mail, facsimile, electronic mail, or telephone, followed by written notification, to the provider, within the applicable time periods set forth in these Authorization/Pre-Certification Rules.H. Upon request of the provider, or the Commission, a payer and/or the review agent must furnish a copy of the license or certification obtained from the State Department of Health, along with all supporting documentation, reports, data, studies, etc., which authorizes the reviewer to engage in authorization/pre-certification activities in the State of Mississippi. The Commission may, likewise, obtain this information unilaterally from the Mississippi Department of Health pursuant to an agreement with that Agency.I. Upon a finding by the Commission or an Administrative Judge that a payer, and/or their review agent, has unreasonably delayed a claim without reasonable grounds within the meaning of § 71-3-59 of the Law, penalties pursuant to MCA § 71-3-59 (Rev. 2000) may be assessed against the payer. Any payer electing to obtain an Employer Medical Evaluation (EME) pursuant to MCA § 71-3-15(1) must do so without unreasonable delay. With respect to an EME sought after the filing of a motion to compel medical treatment by a claimant, failure by the payer to obtain and submit the EME report to the claimant and the Commission within 45 days of the claimant's filing of a motion to compel may be deemed an unreasonable delay. Counsel for both parties may agree to extend the forty-five-day (45-day) limitation, or the Administrative Judge may extend the forty-five-day (45-day) limitation at his or her discretion. The forty-five-day (45-day) limitation does not apply to experts selected by the agreement of both parties to render a second opinion. If an Administrative Judge or the Commission finds that a payer has demonstrated unreasonable delay in seeking or obtaining an EME, regardless of whether a motion to compel medical treatment has been filed, such a finding may result in the imposition of penalties and/or attorney's fees or expenses pursuant to MCA § 71-3-59 and/or waiver of the payer's right to an EME.
J. Nothing provided herein shall estop or prevent the patient from obtaining legal counsel and/or seeking relief in the form of a request to compel medical treatment before an Administrative Judge. Click here to view image