Rule 23-302-2.5 - Provider SelectionA. The beneficiary has ten (10) days to choose his/her Beneficiary Health Management (BHM) designated physician and/or pharmacy provider(s) from the date of receipt of the notification letter. B. The Division of Medicaid will designate a BHM physician and/or pharmacy provider for the beneficiary if the beneficiary does not specify a provider within the ten (10) day time-frame. C. Beneficiaries are required to specify one (1) physician and/or one (1) pharmacy and up to three (3) physician specialists, if requested, for his/her medical and/or pharmacy services while in the Beneficiary Health Management (BHM) program. D. The beneficiary may request a change in his/her BHM physician and/or pharmacy provider if any of the following occur: 1. Change in physical address of the beneficiary or a provider, 2. Death, retirement, or closing of the specified physician, pharmacy and/or specialist, 3. Change in primary diagnosis which requires a different specialist, or 4. The BHM physician and/or pharmacy provider disenrolls or loses eligibility to participate in the Mississippi Medicaid Program. E. The BHM physician or specialist may refer the beneficiary to another provider for consultation by submitting the BHM Referral Form to the Division of Medicaid, Office of Program Integrity, or designee. 1. Prior approval from the Division of Medicaid or designee is required before the beneficiary can be seen by the referring physician. 2. Emergency situations are excluded from this requirement. 3. The referral may cover one (1) or multiple visits as long as those visits are part of the consulting physician's plan of care and are medically necessary. 4. A referral is limited to one (1) year from the date of approval. F. The Division of Medicaid will lock-in beneficiaries to only one (1) pharmacy when one (1) of the following criteria is met: 1. The beneficiary has one (1) or more of the following: a) Received services from four (4) or more prescribers and/or four (4) or more pharmacies relative to controlled substances in the past six (6) months, including emergency department visits, b) A history of substance use disorder within the past twelve (12) months, c) A diagnosis of drug abuse or narcotic poisoning within the past twelve (12) months, or d) Utilizes cash payments to purchase controlled substances. 2. When any written prescription is stolen, forged or altered, 3. When the Division of Medicaid has received a proven report of fraud, waste and/or abuse from one (1) or more of the following: c) Any medical provider, and/or d) Law enforcement entity. 23 Miss. Code. R. 302-2.5
42 C.F.R. § 431.54; Miss. Code Ann §§ 43-13-117, 43-13-121.