Mississippi Administrative Code
Title 23 - Division of Medicaid
Part 202 - Hospital Services
Chapter 1 - Inpatient Services
Rule 23-202-1.3 - Prior Authorization of Inpatient Hospital Services
Universal Citation: MS Code of Rules 23-202-1.3
Current through September 24, 2024
A. Requirement
1. Prior authorization is required from the
appropriate Utilization Management/Quality Improvement Organization (UM/QIO)
for all inpatient hospital admissions except for vaginal deliveries with a
length of stay of two (2) days or less, cesarean deliveries with a length of
stay of four (4) days or less and well newborns with a length of stay of five
(5) days.
a) Emergent admissions and urgent
admissions must be authorized on the next working day after
admission.
b) Failure to obtain the
prior authorization will result in denial of payment to all providers billing
for services including, but not limited to, the hospital and the attending
physician.
2. Prior
authorization must be obtained from the appropriate UM/QIO when a Medicaid
beneficiary:
a) Has third party insurance,
and/or
b) Is also covered by
Medicare Part A only or Medicare Part B only.
3. Prior authorizations are not required for
Medicaid beneficiaries who are also covered by both Medicare Part A and Part B
unless inpatient Medicare benefits are exhausted.
4. Inpatient hospital stays that exceed the
Diagnostic Related Group (DRG) Long Stay Threshold require a Treatment
Authorization Number (TAN) for inpatient days that exceed the
threshold.
B. Non-Approved Services
1. Medicaid
beneficiaries in hospitals shall be billed for inpatient care occurring after
they have received written notification of Medicaid non-approval of hospital
services. Notification prior to the beneficiary's admission shall be cause to
bill the beneficiary for full payment if he/she enters the hospital.
Notification at or after admission shall be cause to bill the beneficiary for
all services provided after receipt of the notice.
2. The hospital cannot bill the Medicaid
beneficiary for an inpatient stay when it is determined upon retrospective
review by the appropriate UM/QIO that the admission did not meet inpatient care
criteria.
C. Maternity-Related Services
1. Hospitals must
report all admissions for deliveries to the Division of Medicaid and the
appropriate UM/QIO. The hospitals must report the admissions in accordance with
the requirements provided by the Division of Medicaid and the appropriate
UM/QIO. A TAN is issued to cover up to nineteen (19) days, the DRG Long Stay
Threshold, for a delivery.
2. For
admissions exceeding nineteen (19) days for a delivery, providers must submit a
request for a continued stay in accordance with the policies and procedures
provided by the appropriate UM/QIO.
D. Newborns
1. Well newborn services provided in the
hospital must be billed separately from the mother's hospital claim.
a) The hospital must notify the Division of
Medicaid within five (5) calendar days of a newborn's birth via the Newborn
Enrollment Form located on the Division of Medicaid's website.
b) The Division of Medicaid will notify the
provider within five (5) business days of the newborn's permanent Medicaid
identification (ID) number.
2. The hospital must obtain a TAN for sick
newborns requiring hospitalization whose length of stay is six (6) days or
more. The baby's date of birth is the sick newborn's beginning date for
certification. A sick newborn whose length of stay exceeds nineteen (19) days
requires a concurrent review by the appropriate UM/QIO.
3. The hospital must obtain authorization for
newborns delivered outside the hospital and newborns admitted to accommodations
other than well baby.
42 USC § 1395f; Miss. Code Ann. §§ 43-13-117, 43-13-121.
Disclaimer: These regulations may not be the most recent version. Mississippi may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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