Section 20-2-VIII - OUT-OF-STATE MEDICAL TREATMENTA. Each employer shall furnish all reasonable and necessary drugs, supplies, hospital care and services, and medical and surgical treatment for the work-related injury or illness. All such care, services, and treatment shall be performed at facilities within the state when available.B. When billing for out-of-state services, supporting documentation is necessary to show that the service being provided cannot be performed within the state, the same quality of care cannot be provided within the state, or more cost-effective care can be provided out-of-state. In determining whether out-of-state treatment is more cost effective, this question must be viewed from both the payer and patient's perspective. Treatment should be provided in an area reasonably convenient to the place of the injury or the residence of the injured employee, in addition to being reasonably suited to the nature of the injury. C. Reimbursement for out-of-state services shall be based on one of the following, in order of preference: (1) the workers' compensation fee schedule for the state in which services are rendered; or(2) in cases where there is no applicable fee schedule for the state in which services are rendered, or the fee schedule in said state excludes or otherwise does not provide reimbursement allowances for the services rendered, reimbursement should be paid at the usual and customary rate for the geographical area in which the services are rendered; or(3) reimbursement for out-of-state services may be based on the mutual agreement of the parties. The Mississippi Workers' Compensation Medical Fee Schedule coding and billing rules apply whenever an injured employee is receiving workers' compensation benefits under Mississippi law or would be entitled to receive benefits under Mississippi law, whether the treatment is in Mississippi or any other state in order for out-of-state providers to obtain reimbursement.D. Prior authorization must be obtained from the payer for referral to out-of-state providers. The documentation must include the following:* Name and location of the out-of-state provider,
* Justification for an out-of-state provider, including qualifications of the provider and description of services being requested.
A.Response Time. The payer must respond within two (2) business days to a request of prior authorization for non-emergency services. B.Federal Facilities. Treatment provided in federal facilities requires authorization from the payer. However, federal facilities are exempt from the billing requirements and reimbursement policies in this manual.C.Pre-certification for Non-emergency Surgery. Providers must pre-certify all non-emergency surgery. However, certain catastrophic cases require frequent returns to the operating room (O.R.) (e.g., burns may require daily surgical debridement). In such cases, it is appropriate for the provider to obtain certification of the treatment plan to include multiple surgical procedures. The provider's treatment plan must be specific and agreement must be mutual between the provider and the payer regarding the number and frequency of procedures certified.D.Retrospective Review. Failure to obtain pre-certification as required by this Fee Schedule shall not, in and of itself, result in a denial of payment for the services provided. Instead, the payer, if requested to do so by the provider within one (1) year of the date of service or discharge, shall conduct a retrospective review of the services, and if the payer determines that the services provided would have been pre-certified, in whole or in part, if pre-certification had been timely sought by the provider, then the payer shall reimburse the provider for the approved services according to the Fee Schedule, or, if applicable, according to the separate fee agreement between the payer and provider, less a ten percent (10%) penalty for the provider's failure to obtain pre-certification as required by this Fee Schedule. This penalty shall be computed as ten percent (10%) of the total allowed reimbursement. If, upon retrospective review, the payer determines that pre-certification would not have been given, or would not have been given as to part of the requested services, then the payer shall dispute the bill and proceed in accordance with the Billing and Reimbursement Rules as hereafter provided. E.Authorization Provided by Employer or Payer. When authorization for treatment is sought and obtained from the employer, or payer, whether verbally or in writing, and medical treatment is rendered in good faith reliance on this authorization, the provider is entitled to payment from the employer or payer for the initial visit or evaluation, or in emergency cases, for treatment which is medically necessary to stabilize the patient. Reimbursement is not dependent on, and payment is due regardless of, the outcome of medically necessary services which are provided in good faith reliance upon authorization given by the employer or payer.20 Miss. Code. R. § 2-VIII