Rule 23-202-1.18 - Review for Medical Necessity and/or Independent Verification and Validation (IV&V)A. The Division of Medicaid defines Review for Medical Necessity and/or Independent Verification and Validation (IV&V) as the Utilization Management/Quality Improvement Organization (UM/QIO) or Division of Medicaid, or designee, review of services of Medicaid beneficiaries in the inpatient setting for including, but not limited to, the following:1. Meeting clinical guidelines for medical necessity. [Refer to Part 200, Rule 5.1 for definition of medical necessity],2. Appropriateness of setting and quality of care,3. Appropriate lengths of stay and services, and4. Correct All Patient Refined Diagnosis Related Groups (APR-DRG) assignment.B. The inpatient hospital provider must submit the requested documentation to the UM/QIO or the Division of Medicaid, or designee, within the specified time frame in the Notice.C. Inpatient hospital providers may request an Administrative Appeal when the provider is dissatisfied with final administrative decisions of the Division of Medicaid relating to disallowances as a result of a review for medical necessity or an IV&V decision described in Miss. Admin. Code Part 202, Rule 1.18.A.D. Providers must comply with the appeal provisions in Miss. Admin. Code Part 300, Rule 1.1.23 Miss. Code. R. 202-1.18
42 CFR Part 456; 45 CFR §307.15(b)(10); Miss. Code Ann. §§ 43-13-117, 43-13-121.