MISSISSIPPI LEGISLATURE

2022 Regular Session

To: Public Health and Human Services

By: Representatives Mims, Felsher

House Bill 780

AN ACT TO CREATE NEW SECTIONS 83-41-501 THROUGH 83-41-517, MISSISSIPPI CODE OF 1972, TO AUTHORIZE AN EXEMPTION FROM PRIOR AUTHORIZATION REQUIREMENTS BY HEALTH INSURERS FOR PHYSICIANS AND OTHER PROVIDERS WHO PROVIDE CERTAIN HEALTH CARE SERVICES; TO PROVIDE THAT A HEALTH INSURER THAT USES A PRIOR AUTHORIZATION PROCESS FOR HEALTH CARE SERVICES MAY NOT REQUIRE A PHYSICIAN OR OTHER PROVIDER TO OBTAIN PRIOR AUTHORIZATION FOR A PARTICULAR HEALTH CARE SERVICE IF, IN THE MOST RECENT SIX-MONTH EVALUATION PERIOD, THE HEALTH INSURER HAS APPROVED OR WOULD HAVE APPROVED NOT LESS THAN 90 PERCENT OF THE PRIOR AUTHORIZATION REQUESTS SUBMITTED FOR THE PARTICULAR HEALTH CARE SERVICE; TO AUTHORIZE A HEALTH INSURER TO RESCIND AN EXEMPTION FROM PRIOR AUTHORIZATION REQUIREMENTS ONLY IF THE HEALTH INSURER MAKES A DETERMINATION, ON THE BASIS OF A RETROSPECTIVE REVIEW OF A RANDOM SAMPLE OF CLAIMS SUBMITTED BY THE PHYSICIAN OR OTHER PROVIDER DURING THE MOST RECENT EVALUATION PERIOD, THAT LESS THAN 90 PERCENT OF THE CLAIMS FOR THE PARTICULAR HEALTH CARE SERVICE MET THE MEDICAL NECESSITY CRITERIA THAT WOULD HAVE BEEN USED BY THE HEALTH INSURER WHEN CONDUCTING PRIOR AUTHORIZATION REVIEW FOR THE PARTICULAR HEALTH CARE SERVICE DURING THE RELEVANT EVALUATION PERIOD; TO PROVIDE THAT SUCH A DETERMINATION MUST BE MADE BY AN INDIVIDUAL LICENSED TO PRACTICE MEDICINE IN THIS STATE; TO PROVIDE THAT A PHYSICIAN OR OTHER PROVIDER HAS A RIGHT TO A REVIEW OF AN ADVERSE DETERMINATION REGARDING A DENIAL OR RESCISSION OF A PRIOR AUTHORIZATION EXEMPTION AND THAT THE REVIEW MUST BE CONDUCTED BY AN ACCREDITED INDEPENDENT REVIEW ORGANIZATION; TO PROVIDE THAT A HEALTH INSURER SHALL PAY FOR ANY APPEAL OR INDEPENDENT REVIEW OF AN ADVERSE DETERMINATION REGARDING A PRIOR AUTHORIZATION EXEMPTION REQUESTED BY A PHYSICIAN OR OTHER PROVIDER; TO PROVIDE THAT A HEALTH INSURER IS BOUND BY AN APPEAL OR INDEPENDENT REVIEW DETERMINATION THAT DOES NOT AFFIRM THE DETERMINATION MADE BY THE HEALTH INSURER TO RESCIND OR DENY A PRIOR AUTHORIZATION EXEMPTION; TO PROVIDE THAT A HEALTH INSURER SHALL NOT DENY OR REDUCE PAYMENT TO A PHYSICIAN OR OTHER PROVIDER FOR A HEALTH CARE SERVICE FOR WHICH THE PHYSICIAN OR OTHER PROVIDER HAS QUALIFIED FOR AN EXEMPTION FROM PRIOR AUTHORIZATION REQUIREMENTS BASED ON MEDICAL NECESSITY OR APPROPRIATENESS OF CARE, UNLESS THE PHYSICIAN OR OTHER PROVIDER KNOWINGLY AND MATERIALLY MISREPRESENTED THE HEALTH CARE SERVICE IN A REQUEST FOR PAYMENT SUBMITTED TO THE HEALTH INSURER WITH THE SPECIFIC INTENT TO DECEIVE AND OBTAIN AN UNLAWFUL PAYMENT FROM THE HEALTH INSURER, OR FAILED TO SUBSTANTIALLY PERFORM THE HEALTH CARE SERVICE; TO AMEND SECTIONS 41-83-9, 41-83-31, 73-23-35, 83-9-6.3, 83-9-32, 83-9-353, 83-41-409 AND 83-51-15, MISSISSIPPI CODE OF 1972, TO CONFORM TO THE PROVISIONS OF THIS ACT; AND FOR RELATED PURPOSES.

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

SECTION 1. The following shall be codified as Section 83-41-501, Mississippi Code of 1972:

83-41-501. (1) Legislative findings and intent. The Legislature finds and declares that certain prior authorization practices employed within the insurance industry have become an integral part of the policy relationship between the insurer and insured and, accordingly, should be regulated in the manner provided for in this article to reduce administrative burdens and promote access to safe and timely care by providers of health care services.

(2) Definitions. As used in this article, the following terms have the meanings as defined in this section, unless the context otherwise requires:

(a) "Health care service" means a service provided to an individual to prevent, alleviate, cure or heal human illness or injury. The term includes:

(i) Pharmaceutical services;

(ii) Medical, chiropractic or dental care; (iii) Hospitalization; or

(iv) Care or services incidental to the foregoing services.

(b) "Health insurer" means any health insurance company, nonprofit hospital and medical service corporation, health maintenance organization, preferred provider organization, managed care organization, pharmacy benefit manager, and, to the extent permitted under federal law, any administrator of an insured, self-insured or publicly funded health care benefit plan offered by public and private entities, and other parties that are by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service.

(c) "Health insurance plan" means any health insurance policy or health insurance plan offered by a health insurer, and includes the State and School Employees Health Insurance Plan and any other public health care assistance program offered or administered by the state or any political subdivision or instrumentality of the state.

(d) "Physician" means an individual licensed to practice medicine in this state.

(e) "Prior authorization" means a determination by a health insurer or person contracting with a health insurer or health insurance plan that health care services proposed to be provided to a patient are medically necessary and appropriate.

(f) "Provider" means an individual, other than a physician, who is licensed or otherwise authorized to provide a health care service in this state, including, but not limited to, a chiropractor, registered nurse, pharmacist or optometrist. The term "provider" does not include a hospital.

SECTION 2. The following shall be codified as Section 83-41-503, Mississippi Code of 1972:

83-41-503. Applicability of article. This article applies only to:

(a) A health insurance plan offered by a health insurer, except that this article does not apply to:

(i) The Mississippi Children's Health Insurance Program, authorized by Chapter 86, Title 41, Mississippi Code of 1972; or

(ii) The state Medicaid program, including the Medicaid managed care program, coordinated care program, coordinated care organization program or health maintenance organization program, authorized by Article 3, Chapter 13, Title 43, Mississippi Code of 1972;

(b) A managed care plan offered by a managed care entity under Article 9, Chapter 41 of Title 83, Mississippi Code of 1972; and

(c) A person who contracts with a health insurer or health insurance plan to issue prior authorization determinations or perform the functions described in this article, including, but not limited to, a private review agent, as defined by Section 41-83-1(b).

SECTION 3. The following shall be codified as Section 83-41-505, Mississippi Code of 1972:

83-41-505. Exemption from prior authorization requirements for physicians and providers providing certain health care services. (1) A health insurer that uses a prior authorization process for health care services may not require a physician or a provider to obtain prior authorization for a particular health care service if, in the most recent six-month evaluation period, as described by subsection (2) of this section, the health insurer has approved or would have approved not less than ninety percent (90%) of the prior authorization requests submitted by the physician or provider for the particular health care service.

(2) Except as provided by subsection (3) of this section, a health insurer shall evaluate whether a physician or provider qualifies for an exemption from prior authorization requirements under subsection (1) of this section once every six (6) months.

(3) A health insurer may continue an exemption under subsection (1) of this section without evaluating whether the physician or provider qualifies for the exemption under subsection (1) of this section for a particular evaluation period.

(4) A physician or provider is not required to request an exemption under subsection (1) of this section to qualify for the exemption.

SECTION 4. The following shall be codified as Section 83-41-507, Mississippi Code of 1972:

83-41-507. Duration of prior authorization exemption. (1) A physician's or provider's exemption from prior authorization requirements under Section 83-41-505 remains in effect until:

(a) The thirtieth day after the date the health insurer notifies the physician or provider of the health insurer's determination to rescind the exemption under Section 83-41-505, if the physician or provider does not appeal the health insurer's determination or request review by an independent review organization as provided for in Section 83-41-511; or

(b) If the physician or provider appeals the determination, the fifth day after the date that the independent review organization, as provided for in section 83-41-511 and 83-41-513, affirms the health insurer's determination to rescind the exemption.

(2) If a health insurer does not finalize a rescission determination as specified in subsection (1) of this section, then the physician or provider is considered to have met the criteria under Section 83-41-505 to continue to qualify for the exemption.

SECTION 5. The following shall be codified as Section 83-41-509, Mississippi Code of 1972:

83-41-509. Denial or rescission of prior authorization exemption. (1) A health insurer may rescind an exemption from prior authorization requirements under Section 83-41-505 only:

(a) During January or June of each year;

(b) If the health insurer makes a determination, on the basis of a retrospective review of a random sample of not fewer than ten (10) and not more than twenty (20) claims submitted by the physician or provider during the most recent evaluation period described by Section 83-41-505(2), that less than ninety percent (90%) of the claims for the particular health care service met the medical necessity criteria that would have been used by the health insurer when conducting prior authorization review for the particular health care service during the relevant evaluation period; and

(i) Notifying the physician or provider not less than twenty-five (25) days before the proposed rescission is to take effect; and

(ii) Providing with the notice to the physician or provider the sample information used to make the determination and a plain language explanation of how the physician or provider may appeal and seek an independent review of the determination.

(2) A determination made under subsection (1)(b) of this section shall be made by an individual licensed to practice medicine in this state. For a determination made under subsection (1)(b) of this section with respect to a physician, the determination shall be made by an individual licensed to practice medicine in this state who is also certified by a board recognized by the American Board of Medical Specialties in the same or similar specialty as the physician.

(3) A health insurer may deny an exemption from prior authorization requirements under Section 83-41-505 only if:

(a) The physician or provider does not have the exemption at the time of the relevant evaluation period; and

(b) The health insurer provides the physician or provider with actual statistics and data for the relevant prior authorization request evaluation period and detailed information sufficient to demonstrate that the physician or provider does not meet the criteria for an exemption from prior authorization requirements for the particular health care service under Section 83-41-505.

SECTION 6. The following shall be codified as Section 83-41-511, Mississippi Code of 1972:

83-41-511. Independent review of exemption determination. (1) A physician or provider has a right to a review of an adverse determination regarding a denial or rescission of a prior authorization exemption and that it be conducted by an accredited independent review organization. A health insurer shall not require a physician or provider to engage in an internal appeal process before requesting a review by an independent review organization under this section.

(2) A health insurer shall pay for any appeal or independent review of an adverse determination regarding a prior authorization exemption requested under this section.

(3) An independent review organization shall complete an expedited review and render a decision with regard to an adverse determination regarding a prior authorization exemption not later than the fifth working day after the date a physician or provider files the request for a review under this section.

(4) A physician or provider may request that the independent review organization consider another random sample of not fewer than ten (10) and not more than twenty (20) claims submitted to the health insurer by the physician or provider during the relevant evaluation period for the relevant health care service as part of its review. If the physician or provider makes a request under this subsection, the independent review organization shall base its determination on the medical necessity of claims reviewed by the health insurer under Section 83-41-509 and reviewed under this subsection.

SECTION 7. The following shall be codified as Section 83-41-513, Mississippi Code of 1972:

83-41-513. Effect of appeal or independent review determination. (1) A health insurer is bound by an appeal or independent review determination that does not affirm the determination made by the health insurer to rescind or deny a prior authorization exemption.

(2) A health insurer shall not retroactively deny a health care service on the basis of a rescission of an exemption, even if the health insurer's determination to rescind the prior authorization exemption is affirmed by an independent review organization.

(3) If a determination of a prior authorization exemption made by the health insurer is overturned on review by an independent review organization, the health insurer:

(a) Shall not attempt to rescind the exemption before the end of the next evaluation period that occurs; and

(b) May only rescind the exemption after the health insurer complies with Sections 83-41-509 and 83-41-511.

SECTION 8. The following shall be codified as Section 83-41-515, Mississippi Code of 1972:

83-41-515. Eligibility for prior authorization exemption following finalized exemption rescission or denial. After a final determination or review affirming the rescission or denial of an exemption for a specific health care service under Section 83-41-505, a physician or provider is eligible for consideration of an exemption for the same health care service after the six-month evaluation period that follows the evaluation period that formed the basis of the rescission or denial of an exemption and a physician or provider is not required to request an exemption to qualify for an exemption.

SECTION 9. The following shall be codified as Section 83-41-517, Mississippi Code of 1972:

83-41-517. Effect of prior authorization exemption. (1) A health insurer shall not deny or reduce payment to a physician or provider for a health care service for which the physician or provider has qualified for an exemption from prior authorization requirements under Section 83-41-505 based on medical necessity or appropriateness of care unless the physician or provider:

(a) Knowingly and materially misrepresented the health care service in a request for payment submitted to the health insurer with the specific intent to deceive and obtain an unlawful payment from the health insurer; or

(b) Failed to substantially perform the health care service.

(2) A health insurer shall not conduct a retrospective review of a health care service subject to an exemption except:

(a) To determine if the physician or provider still qualifies for an exemption under this article; or

(b) If the health insurer has a reasonable cause to suspect a basis for denial exists under subsection (1) of this section.

(3) For a retrospective review described by subsection (2) of this section, nothing in this article shall be construed to modify or otherwise affect:

(a) The requirements under or application of Chapter 83, Title 41, Mississippi Code of 1972, including any timeframes specified by that chapter; or

(b) Any other applicable law, except to prescribe the only circumstances under which:

(i) A retrospective utilization review may occur as specified by subsection (2)(b) of this section; or

(ii) Payment may be denied or reduced as specified by subsection (1) of this section.

(4) Not later than five (5) working days after qualifying for an exemption from prior authorization requirements under Section 83-41-505, a health insurer shall provide to a physician or provider a notice that includes:

(a) A statement that the physician or provider qualifies for an exemption from prior authorization requirements under Section 83-41-505;

(b) A list of the health care services and health insurance plans to which the exemption applies; and

(5) If a physician or provider submits a prior authorization request for a health care service for which the physician or provider qualifies for an exemption from prior authorization requirements under Section 83-41-505, the health insurer shall promptly provide a notice to the physician or provider that includes:

(a) The information described by subsection (4) of this section; and

(b) A notification of the health insurer's payment requirements.

(6) Nothing in this article shall be construed to:

(a) Authorize a physician or provider to provide a health care service outside the scope of the physician's or provider's applicable professional license; or

(b) Require a health insurer to pay for a health care service described by paragraph (a) of this subsection that is performed in violation of the laws of this state.

SECTION 10. Sections 1 through 9 of this act shall be codified as a new Article 11 in Chapter 41, Title 83, Mississippi Code of 1972.

SECTION 11. Section 41-83-9, Mississippi Code of 1972, is amended as follows:

41-83-9. In conjunction with the application, the private review agent shall submit information that the department requires including:

(a) A utilization review plan that includes:

(i) A description of review criteria, standards and procedures to be used in evaluating proposed or delivered hospital and medical care and the provisions by which patients, physicians or hospitals may seek reconsideration or appeal of adverse decisions by the private review agent; and

(ii) Policies and procedures to exempt from prior authorization requirements physicians or providers providing certain health care services, pursuant to the provisions of Article 11, Chapter 41, Title 83, Mississippi Code of 1972;

(b) The type and qualifications of the personnel either employed or under contract to perform the utilization review;

(c) The procedures and policies to insure that a representative of the private review agent is reasonably accessible to patients and providers at all times in this state;

(d) The policies and procedures to insure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed;

(e) A copy of the materials designed to inform applicable patients and providers of the requirements of the utilization review plan; and

(f) A list of the third party payors for which the private review agent is performing utilization review in this state.

SECTION 12. Section 41-83-31, Mississippi Code of 1972, is amended 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 prior evaluation and concurrence in the adverse determination by a physician licensed to practice in Mississippi and, in the case of health care services furnished by a physician, certified by a board recognized by the American Board of Medical Specialties in the same or similar specialty as the physician. The physician who made the adverse determination shall provide the health care provider who ordered, requested, provided or is to provide the health care service a reasonable opportunity to discuss the reasons for any adverse determination * * * before an adverse determination is issued by a private review agent. 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 * * * licensed to practice medicine in this state and, in the case of a health care service rendered by a physician, certified by a board recognized by the American Board of Medical Specialties in the same or similar specialty as the physician, to make a final determination that care rendered or to be rendered was, is, or may be medically inappropriate.

(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.

SECTION 13. Section 73-23-35, Mississippi Code of 1972, is amended as follows:

73-23-35. (1) A person, corporation, association or business entity shall not use in connection with that person's or party's name or the name or activity of the business the words "physical therapy," "physical therapist," "physiotherapy," "physiotherapist," "registered physical therapist," "doctor of physical therapy," "physical therapist assistant," the letters "PT," "DPT," "LPT," "RPT," "PTA," "LPTA," and/or any other words, abbreviations, or insignia indicating or implying directly or indirectly that physical therapy is provided or supplied unless such services are provided by or under the direction of a physical therapist or physical therapist assistant, as the case may be, with a valid and current license issued pursuant to this chapter or with the privilege to practice. It shall be unlawful to employ an unlicensed physical therapist or physical therapist assistant to provide physical therapy services.

(2) The board shall aid the state's attorneys of the various counties in the enforcement of the provisions of this chapter and the prosecution of any violations thereof. In addition to the criminal penalties provided by this chapter, the civil remedy of injunction shall be available to restrain and enjoin violations of any provisions of this chapter without proof of actual damages sustained by any person. For purposes of this chapter, the board, in seeking an injunction, need only show that the defendant violated subsection (1) of this section to establish irreparable injury or a likelihood of a continuation of the violation.

(3) A physical therapist licensed under this chapter or privileged to practice shall not perform physical therapy services without a prescription or referral from a person licensed as a physician, dentist, osteopath, podiatrist, chiropractor, physician assistant or nurse practitioner. However, a physical therapist licensed under this chapter or privileged to practice may perform physical therapy services without a prescription or referral under the following circumstances:

(a) To children with a diagnosed developmental disability pursuant to the patient's plan of care.

(b) As part of a home health care agency pursuant to the patient's plan of care.

(d) Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress or promotion of fitness.

(e) (i) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis must have been made within the previous one hundred eighty (180) days. The physical therapist shall provide the health care provider who rendered the diagnosis with a plan of care for physical therapy services within the first fifteen (15) days of physical therapy intervention.

(ii) Nothing in this chapter shall create liability of any kind for the health care provider rendering the diagnosis under this paragraph (e) for a condition, illness or injury that manifested itself after the diagnosis, or for any alleged damages as a result of physical therapy services performed without a prescription or referral from a person licensed as a physician, dentist, osteopath, podiatrist, chiropractor, physician assistant or nurse practitioner, the diagnosis and/or prescription for physical therapy services having been rendered with reasonable care.

(4) Physical therapy services performed without a prescription or referral from a person licensed as a physician, dentist, osteopath, podiatrist, chiropractor, physician assistant or nurse practitioner shall not be construed to mandate coverage for physical therapy services under any health care plan, insurance policy, or workers' compensation or circumvent any requirement for preauthorization of services in accordance with any health care plan, insurance policy or workers' compensation.

(5) Nothing in this section shall restrict the Division of Medicaid from setting rules and regulations regarding the coverage of physical therapy services and nothing in this section shall amend or change the Division of Medicaid's schedule of benefits, exclusions and/or limitations related to physical therapy services as determined by state or federal regulations and state and federal law.

(6) Nothing in this section shall require a physician, physical therapist or other provider to obtain preauthorization or prior authorization for physical therapy services or other health care services described in this section if the physician, physical therapist or other provider is exempt from the requirement of obtaining a prior authorization pursuant to the authority of Article 11, Chapter 41, Title 83, Mississippi Code of 1972.

SECTION 14. Section 83-9-6.3, Mississippi Code of 1972, is amended as follows:

83-9-6.3. (1) As used in this section:

(a) "Health benefit plan" means services consisting of medical care, provided directly, through insurance or reimbursement, or otherwise, and including items and services paid for as medical care under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization, or health maintenance organization contract offered by a health insurance issuer. The term "health benefit plan" includes the Medicaid fee-for-service program and any managed care program, coordinated care program, coordinated care organization program or health maintenance organization program implemented by the Division of Medicaid.

(b) "Health insurance issuer" means any entity that offers health insurance coverage through a health benefit plan, policy, or certificate of insurance subject to state law that regulates the business of insurance. "Health insurance issuer" also includes a health maintenance organization, as defined and regulated under Section 83-41-301 et seq., and includes the Division of Medicaid for the services provided by fee-for-service and through any managed care program, coordinated care program, coordinated care organization program or health maintenance organization program implemented by the division.

(c) "Prior authorization" means a utilization management criterion used to seek permission or waiver of a drug to be covered under a health benefit plan that provides prescription drug benefits.

(d) "Prior authorization form" means a standardized, uniform application developed by a health insurance issuer for the purpose of obtaining prior authorization.

(2) Notwithstanding any other provision of law to the contrary, in order to establish uniformity in the submission of prior authorization forms, on or after January 1, 2014, a health insurance issuer shall use only a single, standardized prior authorization form for obtaining any prior authorization for prescription drug benefits. The form shall not exceed two (2) pages in length, excluding any instructions or guiding documentation. The form shall also be made available electronically, and the prescribing provider may submit the completed form electronically to the health benefit plan. Additionally, the health insurance issuer shall submit its prior authorization forms to the Mississippi Department of Insurance to be kept on file on or after January 1, 2014. A copy of any subsequent replacements or modifications of a health insurance issuer's prior authorization form shall be filed with the Mississippi Department of Insurance within fifteen (15) days prior to use or implementation of such replacements or modifications.

(3) A health insurance issuer shall respond within two (2) business days upon receipt of a completed prior authorization request from a prescribing provider that was submitted using the standardized prior authorization form required by subsection (2) of this section.

(4) Nothing in this section shall require a prescribing provider to obtain a prior authorization if the prescribing provider is exempt from the requirement of obtaining a prior authorization pursuant to the authority of Article 11, Chapter 41, Title 83, Mississippi Code of 1972.

SECTION 15. Section 83-9-32, Mississippi Code of 1972, is amended as follows:

83-9-32. (1) Every hospital, health or medical expenses insurance policy, hospital or medical service contract, health maintenance organization and preferred provider organization that is delivered or issued for delivery in this state and otherwise provides anesthesia benefits shall offer benefits for anesthesia and for associated facility charges when the mental or physical condition of the child or mentally handicapped adult requires dental treatment to be rendered under physician-supervised general anesthesia in a hospital setting, surgical center or dental office. This coverage shall be offered on an optional basis, and each primary insured must accept or reject such coverage in writing and accept responsibility for premium payment.

(2) An insurer may require prior authorization for the anesthesia and associated facility charges for dental care procedures in the same manner that prior authorization is required for treatment of other medical conditions under general anesthesia. An insurer may require review for medical necessity and may limit payment of facility charges to certified facilities in the same manner that medical review is required and payment of facility charges is limited for other services. The benefit provided by this coverage shall be subject to the same annual deductibles or coinsurance established for all other covered benefits within a given policy, plan or contract. Private third-party payers may not reduce or eliminate coverage due to these requirements.

(3) A dentist shall consider the Indications for General Anesthesia as published in the reference manual of the American Academy of Pediatric Dentistry as utilization standards for determining whether performing dental procedures necessary to treat the particular condition or conditions of the patient under general anesthesia constitutes appropriate treatment.

(4) The provisions of this section shall apply to anesthesia services provided by oral and maxillofacial surgeons as permitted by the Mississippi State Board of Dental Examiners.

(5) The provisions of this section shall not apply to treatment rendered for temporal mandibular joint (TMJ) disorders.

(6) Nothing in this section shall require a physician, dentist or other provider to obtain prior authorization for a health care service described in this section if the dentist or other provider is exempt from the requirement of obtaining a prior authorization pursuant to the authority of Article 11, Chapter 41, Title 83, Mississippi Code of 1972.

SECTION 16. Section 83-9-353, Mississippi Code of 1972, is amended as follows:

83-9-353. (1) As used in this section:

(a) "Employee benefit plan" means any plan, fund or program established or maintained by an employer or by an employee organization, or both, to the extent that such plan, fund or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, medical, surgical, hospital care or other benefits.

(b) "Health insurance plan" means any health insurance policy or health benefit plan offered by a health insurer, and includes the State and School Employees Health Insurance Plan and any other public health care assistance program offered or administered by the state or any political subdivision or instrumentality of the state. The term does not include policies or plans providing coverage for specified disease or other limited benefit coverage.

(c) "Health insurer" means any health insurance company, nonprofit hospital and medical service corporation, health maintenance organization, preferred provider organization, managed care organization, pharmacy benefit manager, and, to the extent permitted under federal law, any administrator of an insured, self-insured or publicly funded health care benefit plan offered by public and private entities, and other parties that are by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.

(d) "Store-and-forward telemedicine services" means the use of asynchronous computer-based communication between a patient and a consulting provider or a referring health care provider and a medical specialist at a distant site for the purpose of diagnostic and therapeutic assistance in the care of patients who otherwise have no access to specialty care. Store-and-forward telemedicine services involve the transferring of medical data from one (1) site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation.

(e) "Remote patient monitoring services" means the delivery of home health services using telecommunications technology to enhance the delivery of home health care, including:

(i) Monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry and other condition-specific data, such as blood glucose;

(ii) Medication adherence monitoring; and

(iii) Interactive video conferencing with or without digital image upload as needed.

(f) "Mediation adherence management services" means the monitoring of a patient's conformance with the clinician's medication plan with respect to timing, dosing and frequency of medication-taking through electronic transmission of data in a home telemonitoring program.

(2) Store-and-forward telemedicine services allow a health care provider trained and licensed in his or her given specialty to review forwarded images and patient history in order to provide diagnostic and therapeutic assistance in the care of the patient without the patient being present in real time. Treatment recommendations made via electronic means shall be held to the same standards of appropriate practice as those in traditional provider-patient setting.

(3) Any patient receiving medical care by store-and-forward telemedicine services shall be notified of the right to receive interactive communication with the distant specialist health care provider and shall receive an interactive communication with the distant specialist upon request. If requested, communication with the distant specialist may occur at the time of the consultation or within thirty (30) days of the patient's notification of the request of the consultation. Telemedicine networks unable to offer the interactive consultation shall not be reimbursed for store-and-forward telemedicine services.

(4) Remote patient monitoring services aim to allow more people to remain at home or in other residential settings and to improve the quality and cost of their care, including prevention of more costly care. Remote patient monitoring services via telehealth aim to coordinate primary, acute, behavioral and long-term social service needs for high-need, high-cost patients. Specific patient criteria must be met in order for reimbursement to occur.

(5) Qualifying patients for remote patient monitoring services must meet all the following criteria:

(a) Be diagnosed, in the last eighteen (18) months, with one or more chronic conditions, as defined by the Centers for Medicare and Medicaid Services (CMS), which include, but are not limited to, sickle cell, mental health, asthma, diabetes, and heart disease; and

(b) The patient's health care provider recommends disease management services via remote patient monitoring.

(6) A remote patient monitoring prior authorization request form may be required for approval of telemonitoring services unless the physician or provider is exempt from the requirement of obtaining a prior authorization pursuant to the authority of Article 11, Chapter 41, Title 83, Mississippi Code of 1972. If prior authorization is required, the request form must include the following:

(a) An order for home telemonitoring services, signed and dated by the prescribing physician;

(b) A plan of care, signed and dated by the prescribing physician, that includes telemonitoring transmission frequency and duration of monitoring requested;

(d) Attestation that the client is sufficiently cognitively intact and able to operate the equipment or has a willing and able person to assist in completing electronic transmission of data; and

(e) Attestation that the client is not receiving duplicative services via disease management services.

(7) The entity that will provide the remote monitoring must be a Mississippi-based entity and have protocols in place to address all of the following:

(a) Authentication and authorization of users;

(b) A mechanism for monitoring, tracking and responding to changes in a client's clinical condition;

(c) A standard of acceptable and unacceptable parameters for client's clinical parameters, which can be adjusted based on the client's condition;

(d) How monitoring staff will respond to abnormal parameters for client's vital signs, symptoms and/or lab results;

(e) The monitoring, tracking and responding to changes in client's clinical condition;

(f) The process for notifying the prescribing physician for significant changes in the client's clinical signs and symptoms;

(g) The prevention of unauthorized access to the system or information;

(h) System security, including the integrity of information that is collected, program integrity and system integrity;

(i) Information storage, maintenance and transmission;

(j) Synchronization and verification of patient profile data; and

(k) Notification of the client's discharge from remote patient monitoring services or the de-installation of the remote patient monitoring unit.

(8) The telemonitoring equipment must:

(a) Be capable of monitoring any data parameters in the plan of care; and

(b) Be a FDA Class II hospital-grade medical device.

(9) Monitoring of the client's data shall not be duplicated by another provider.

(10) To receive payment for the delivery of remote patient monitoring services via telehealth, the service must involve:

(a) An assessment, problem identification, and evaluation that includes:

(i) Assessment and monitoring of clinical data including, but not limited to, appropriate vital signs, pain levels and other biometric measures specified in the plan of care, and also includes assessment of response to previous changes in the plan of care; and

(ii) Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care.

(b) Implementation of a management plan through one or more of the following:

(i) Teaching regarding medication management as appropriate based on the telemedicine findings for that encounter;

(ii) Teaching regarding other interventions as appropriate to both the patient and the caregiver;

(iii) Management and evaluation of the plan of care including changes in visit frequency or addition of other skilled services;

(iv) Coordination of care with the ordering health care provider regarding telemedicine findings;

(v) Coordination and referral to other medical providers as needed; and

(vi) Referral for an in-person visit or the emergency room as needed.

(11) The telemedicine equipment and network used for remote patient monitoring services should meet the following requirements:

(a) Comply with applicable standards of the United States Food and Drug Administration;

(b) Telehealth equipment be maintained in good repair and free from safety hazards;

(d) Accommodate non-English language options; and

(e) Have 24/7 technical and clinical support services available for the patient user.

(12) All health insurance and employee benefit plans in this state must provide coverage and reimbursement for the asynchronous telemedicine services of store-and-forward telemedicine services and remote patient monitoring services based on the criteria set out in this section. Store-and-forward telemedicine services shall be reimbursed to the same extent that the services would be covered if they were provided through in-person consultation.

(13) Remote patient monitoring services shall include reimbursement for a daily monitoring rate at a minimum of Ten Dollars ($10.00) per day each month and Sixteen Dollars ($16.00) per day when medication adherence management services are included, not to exceed thirty-one (31) days per month. These reimbursement rates are only eligible to Mississippi-based telehealth programs affiliated with a Mississippi health care facility.

(14) A one-time telehealth installation/training fee for remote patient monitoring services will also be reimbursed at a minimum rate of Fifty Dollars ($50.00) per patient, with a maximum of two (2) installation/training fees/calendar year. These reimbursement rates are only eligible to Mississippi-based telehealth programs affiliated with a Mississippi health care facility.

(15) No geographic restrictions shall be placed on the delivery of telemedicine services in the home setting other than requiring the patient reside within the State of Mississippi.

(16) Health care providers seeking reimbursement for store-and-forward telemedicine services must be licensed Mississippi providers that are affiliated with an established Mississippi health care facility in order to qualify for reimbursement of telemedicine services in the state. If a service is not available in Mississippi, then a health insurance or employee benefit plan may decide to allow a non-Mississippi-based provider who is licensed to practice in Mississippi reimbursement for those services.

(17) A health insurance or employee benefit plan may charge a deductible, co-payment, or coinsurance for a health care service provided through store-and-forward telemedicine services or remote patient monitoring services so long as it does not exceed the deductible, co-payment, or coinsurance applicable to an in-person consultation.

(18) A health insurance or employee benefit plan may limit coverage to health care providers in a telemedicine network approved by the plan.

(19) Nothing in this section shall be construed to prohibit a health insurance or employee benefit plan from providing coverage for only those services that are medically necessary, subject to the terms and conditions of the covered person's policy.

(20) In a claim for the services provided, the appropriate procedure code for the covered service shall be included with the appropriate modifier indicating telemedicine services were used. A "GQ" modifier is required for asynchronous telemedicine services such as store-and-forward and remote patient monitoring.

(21) The originating site is eligible to receive a facility fee, but facility fees are not payable to the distant site.

SECTION 17. Section 83-41-409, Mississippi Code of 1972, is amended as follows:

83-41-409. In order to be certified and recertified under this article, a managed care plan shall:

(a) Provide enrollees or other applicants with written information on the terms and conditions of coverage in easily understandable language including, but not limited to, information on the following:

(i) Coverage provisions, benefits, limitations, exclusions and restrictions on the use of any providers of care;

(ii) Summary of utilization review and quality assurance policies; and

(iii) Enrollee financial responsibility for copayments, deductibles and payments for out-of-plan services or supplies;

(b) Demonstrate that its provider network has providers of sufficient number throughout the service area to assure reasonable access to care with minimum inconvenience by plan enrollees;

(c) File a summary of the plan credentialing criteria and process and policies with the State Department of Insurance to be available upon request;

(d) Provide a participating provider with a copy of his/her individual profile if economic or practice profiles, or both, are used in the credentialing process upon request;

(e) When any provider application for participation is denied or contract is terminated, the reasons for denial or termination shall be reviewed by the managed care plan upon the request of the provider; * * * ~~and~~

(f) Establish procedures to ensure that all applicable state and federal laws designed to protect the confidentiality of medical records are followed * * *.; and

(g) Establish and comply with policies and procedures to exempt from prior authorization requirements physicians or providers providing certain health care services, pursuant to the provisions of Article 11, Chapter 41, Title 83, Mississippi Code of 1972.

SECTION 18. Section 83-51-15, Mississippi Code of 1972, is amended as follows:

83-51-15. (1) (a) A dental service contractor or a contract of dental insurance shall establish and maintain appeal procedures for any claim by a dentist or a subscriber that is denied based upon lack of medical necessity.

(b) Any denial shall be based upon a determination by a dentist who holds a nonrestricted license issued in the United States in the same or an appropriate specialty that typically manages the dental condition, procedure, or treatment under review.

(c) Subsequent to an initial denial, the licensed dentist making the adverse determination shall not be an employee of the dental service contractor or dental insurer.

(d) Any written communication to an insured or a dentist that includes or pertains to a denial of benefits for all or part of a claim on the basis of a lack of medical necessity shall include the name, applicable specialty designation, license number together with state of issuance, and the email address of the licensed dentist making the adverse determination.

(2) (a) For the purposes of this subsection, a "prior authorization" shall mean any predetermination, prior authorization or similar authorization that is verifiable, whether through issuance of letter, facsimile, e-mail or similar means, indicating that a specific procedure is, or multiple procedures are, covered under the patient's plan and reimbursable at a specific amount, subject to applicable coinsurance and deductibles, and issued in response to a request submitted by a dentist using a prescribed format.

(b) A dental service contractor shall not deny any claim subsequently submitted for procedures specifically included in a prior authorization unless at least one (1) of the following circumstances applies for each procedure denied:

(i) Benefit limitations such as annual maximums and frequency limitations not applicable at the time of prior authorization are reached due to utilization subsequent to issuance of the prior authorization;

(ii) The documentation for the claim provided by the person submitting the claim clearly fails to support the claim as originally authorized;

(iii) If, subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the patient's condition occurs such that the prior authorized procedure would no longer be considered medically necessary, based on the prevailing standard of care;

(iv) If, subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the patient's condition occurs such that the prior authorized procedure would at that time require disapproval pursuant to the terms and conditions for coverage under the patient's plan in effect at the time the prior authorization was issued; or

(v) The dental service contractor's denial is because of one (1) of the following:

1. Another payor is responsible for the payment;

2. The dentist has already been paid for the procedures identified on the claim;

3. The claim was submitted fraudulently or the prior authorization was based in whole or material part on erroneous information provided to the dental service contractor by the dentist, patient, or other person not related to the carrier; or

4. The person receiving the procedure was not eligible to receive the procedure on the date of service and the dental service contractor did not know, and with the exercise of reasonable care could not have known, of the person's eligibility status.

(c) A dental service contractor shall not require any information be submitted for a prior authorization request that would not be required for submission of a claim.

(d) A dental service contractor shall issue a prior authorization within thirty (30) days of the date a request is submitted by a dentist.

(e) The provisions of subsection (1) of this section shall apply to any denial of a claim pursuant to paragraph (b) of this subsection for a procedure included in a prior authorization.

(3) A contractor shall not recoup a claim solely due to a patient's loss of coverage or ineligibility if, at the time of treatment, the contractor erroneously confirms coverage and eligibility, but had sufficient information available to it indicating that the patient was no longer covered or was ineligible for coverage.

(4) Nothing in this section shall require a dentist or other provider to obtain prior authorization for a health care service described in this section if the dentist or other provider is exempt from the requirement of obtaining a prior authorization pursuant to the authority of Article 11, Chapter 41, Title 83, Mississippi Code of 1972.

SECTION 19. Article 11, Chapter 41, Title 83, Mississippi Code of 1972, as added by this act, applies only to a request for prior authorization of a health care service made on or after January 1, 2023. A request for prior authorization of health care services made before January 1, 2023, is governed by the law as it existed immediately before the effective date of this act, and that law is continued in effect for that purpose.

SECTION 20. This act shall take effect and be in force from and after its passage.