Mississippi Administrative Code
Title 20 - Labor
Part 2 - Mississippi Workers' Compensation Medical Fee Schedule
AUTHORIZATION/PRE-CERTIFICATION RULES
The Mississippi Workers' Compensation Commission requires mandatory authorization/pre-certification of certain medical services associated with the provision of medical treatment covered under the Act and subject to the Fee Schedule. "Pre-certification" refers to a system for reviewing proposed medical services to make sure that such procedures are medically necessary and represent the most efficient and appropriate use of medical resources given the nature of the injury to the patient and the process of his or her recovery, and that such services are properly and timely reimbursed. These rules are set forth to encourage efficient and timely communication between payers and providers (including agents of either) in order to make sure that medically necessary services are provided and timely reimbursed, and to curtail the use of unnecessary or unreasonable treatment. The provisions herein set forth regarding pre-certification are in addition to the requirements of Mississippi Code Annotated (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. In the event of conflict between this Fee Schedule and the above statutes, and any implementing regulations adopted by the Health Department or Board of Medical Licensure, the provisions in this Fee Schedule or other applicable rules of the MWCC shall control.
A payer may provide for pre-certification by using personnel or units in-house, by contracting with a third party utilization review agent properly licensed by the MS Department of Health, or by contracting with a Nurse Case Manager or similar person to monitor the care being provided in person working with the patient and provider. An injured worker and/or his or her attorney and any case manager assigned by the payer shall strive to cooperate with one another for the purpose of ensuring the injured worker receives all of the medically necessary care needed for the treatment of the injury and the process of recovery. A payer also may exercise their statutory right to an Employer Medical Evaluation (EME) as provided for in MCA § 71-3-15(1) (Rev. 2000) in conjunction with, or in lieu of, ongoing pre-certificationauthorization/pre-certification.
NO DECISION OR DETERMINATION ADVERSE TO A PATIENT OR HEALTH CARE PROVIDER WHICH MAY RESULT IN THE DENIAL OF PAYMENT, OR IN THE DENIAL OF PRE-CERTIFICATION FOR TREATMENT IN THIS STATE, SHALL BE MADE WITHOUT THE PRIOR EVALUATION AND CONCURRENCE IN THE ADVERSE DETERMINATION BY A PHYSICIAN CURRENTLY LICENSED TO PRACTICE MEDICINE IN THE STATE OF MISSISSIPPI, AND PROPERLY TRAINED IN THE SAME SPECIALTY OR SUB-SPECIALTY AS THE REQUESTING PROVIDER WHO IS SEEKING APPROVAL FOR TREATMENT OR SERVICES.
THIS ADVERSE DETERMINATION MUST BE PROVIDED WITHIN TWO (2) BUSINESS DAYS EITHER BY TELEPHONE OR FACSIMILE OR EMAIL, AND IN WRITING WITHIN ONE (1) BUSINESS DAY THEREAFTER, TO THE REQUESTING PROVIDER. ANY SUCH ADVERSE DETERMINATION MUST INCLUDE WRITTEN DOCUMENTATION CONTAINING THE SPECIFIC EVALUATION, FINDINGS AND CONCURRENCE OF THE MISSISSIPPI LICENSED PHYSICIAN TRAINED IN THE RELEVANT SPECIALTY OR SUB-SPECIALTY, AND MUST REFERENCE ANY SPECIFIC PROVISIONS OF THE MISSISSIPPI WORKERS' COMPENSATION MEDICAL FEE SCHEDULE WHICH ALLEGEDLY JUSTIFIES THE ADVERSE DETERMINATION.
ANY ADVERSE DETERMINATION WHICH DOES NOT COMPLY WITH THIS PROVISION SHALL HAVE NO FORCE
OR EFFECT AND SHALL NOT PREVENT THE PROVIDER FROM PROCEEDING WITH THE PROPOSED TREATMENT AND ULTIMATELY BEING REIMBURSED AS THOUGH THE PROPOSED TREATMENT OR SERVICE HAD BEEN TIMELY APPROVED IN ADVANCE.
IF A PAYER ELECTS TO SEEK AN EME IN LIEU OF AUTHORIZATION/PRE-CERTIFICATION, THE INJURED WORKER AND THE PROVIDER MUST BE NOTIFIED OF THIS ELECTION WITHIN THE SAME TWO (2) DAY PERIOD APPLICABLE TO ADVERSE DETERMINATIONS STATED ABOVE.
