MISSISSIPPI LEGISLATURE

2000 Regular Session

To: Insurance

By: Senator(s) White (5th)

AN ACT TO AMEND SECTION 41-83-31, MISSISSIPPI CODE OF 1972, TO PROVIDE THAT ENROLLEES AND PROVIDERS OF HEALTH CARE SERVICES MAY APPEAL ADVERSE DECISIONS BY UTILIZATION REVIEW ENTITIES TO THE MISSISSIPPI DEPARTMENT OF INSURANCE, AND THAT IN THE EVENT SUCH ADVERSE DECISION IS OVERRULED ON APPEAL, THE THIRD-PARTY REIMBURSEMENT SHALL INCLUDE THE FULL COST OF THE SERVICE INCLUDING ANY DEDUCTIBLE AMOUNT PAID OR OWED BY THE ENROLLEE; AND FOR RELATED PURPOSES.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:

SECTION 1. Section 41-83-31, Mississippi Code of 1972, is amended as follows:

[Until December 31, 2000, this section shall read as follows:]

41-83-31. Any program of utilization review with regard to hospital, medical or other health care services provided in this state shall comply with the following:

(a) No determination adverse to a patient or to any affected health care provider shall be made on any question relating to the necessity or justification for any form of hospital, medical or other health care services without an independent prior evaluation and concurrence in the adverse determination by a physician licensed to practice in Mississippi. The physician who made the adverse determination shall discuss the reasons for any adverse determination with the affected health care provider, if the provider so requests. The physician shall comply with this request within fourteen (14) calendar days of being notified of a request. Adverse determination by a physician shall not be grounds for any disciplinary action against the physician by the State Board of Medical Licensure.

(b) Any determination regarding hospital, medical or other health care services rendered or to be rendered to a patient which may result in a denial of third-party reimbursement or a denial of precertification for that service shall include the evaluation, findings and concurrence of a physician trained in the relevant specialty or subspecialty, if requested by the patient's physician, to make a final determination that care rendered or to be rendered was, is, or may be medically inappropriate. Enrollees and providers shall have the right to protest decisions denying third-party reimbursement or precertification of a service, and to appeal this adverse decision to the Mississippi Department of Insurance in a manner acceptable to the department. In the event a decision denying third-party reimbursement or precertification is overruled on appeal, the third-party payor shall reimburse the full cost of the service, including any deductible amount. In the event the medical or health care service was performed pending appeal by the enrollee or the provider, the enrollee and the provider shall be reimbursed jointly for the full cost of the service including any deductible amount. The Mississippi Department of Insurance shall annually report to the Legislature the number of complaints received by enrollees, the nature of each complaint and the manner in which each complaint was resolved.

(c) The requirement in this section that the physician who makes the evaluation and concurrence in the adverse determination must be licensed to practice in Mississippi shall not apply to the Comprehensive Health Insurance Risk Pool Association or its policyholders and shall not apply to any utilization review company which reviews fewer than ten (10) persons residing in the State of Mississippi.

[From and after January 1, 2001, this section shall read as follows:]

41-83-31. Any program of utilization review with regard to hospital, medical or other health care services provided in this state shall comply with the following:

(a) No determination adverse to a patient or to any affected health care provider shall be made on any question relating to the necessity or justification for any form of hospital, medical or other health care services without an independent prior evaluation and concurrence in the adverse determination by a physician. The reasons for any adverse determination shall be discussed by said physician with the affected health care provider, if the provider so requests.

(b) Any determination regarding hospital, medical or other health care services rendered or to be rendered to a patient which may result in a denial of third-party reimbursement or a denial of precertification for that service shall include the evaluation, findings and concurrence of a physician trained in the relevant specialty or subspecialty, if requested by the patient's physician, to make a final determination that care rendered or to be rendered was, is, or may be medically inappropriate. Enrollees and providers shall have the right to protest decisions denying third-party reimbursement or precertification of a service, and to appeal this adverse decision to the Mississippi Department of Insurance in a manner acceptable to the department. In the event a decision denying third-party reimbursement or precertification is overruled on appeal, the third-party payor shall reimburse the full cost of the service, including any deductible amount. In the event the medical or health care service was performed pending appeal by the enrollee or the provider, the enrollee and the provider shall be reimbursed jointly for the full cost of the service including any deductible amount. The Mississippi Department of Insurance shall annually report to the Legislature the number of complaints received by enrollees, the nature of each complaint and the manner in which each complaint was resolved.

SECTION 2. This act shall take effect and be in force from and after July 1, 2000.