Department of Insurance

A. A health insurance issuer shall not, except as provided in subsection B. of this Section: 1. Restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child following a normal vaginal delivery to less than forty-eight (48) hours;…

A health insurance issuer offering a group or individual health insurance coverage shall not: A. Deny to the mother or her newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy solely for the purpose of avoiding the requ…

A. Nothing in this Regulation shall be construed to require a mother who is an insured or enrollee: 1. To give birth in a hospital; or 2. To stay in the hospital for a fixed period of time following the birth of her child. B. This Regulation shall not apply with respect to any gr…

A health insurance issuer providing group or individual health insurance coverage shall provide notice to the named insured in the case of an individual policy, and to each certificate holder in the case of a group policy, regarding the coverage required by this Regulation. Such …

The effective date of this Regulation shall be thirty (30) days from and after its adoption and filing with the Secretary of State of the State of Mississippi. Notes 19 Miss. Code. R. 3-12.08 Miss. Code Ann. § 25-43-3.113 (Rev. 2010)

This Regulation is promulgated pursuant to the authority vested in the Commissioner of Insurance under Miss. Code Ann. §§ 83-1-43 and 83-5-1 (Rev. 1999).and is promulgated in accordance with Mississippi Insurance Department Regulation No. 88-101, said Regulation being the Rules o…

In order to fully comply with the Health Insurance Portability and Accountability Act of 1996, as Amended, including instructions issued by the Health Care Financing Administration regarding the enforcement thereof, this Regulation is promulgated to require health insurance issue…

As used in this Regulation, the term "health insurance issuer" shall mean any insurance company, hospital or medical service plan or any entity defined in Miss. Code Ann. § 83-41-303(n)(Rev. 1999), which offers group or individual health insurance coverage in the State of Mississ…

A health insurance issuer providing group or individual health insurance coverage that provides medical and surgical benefits with respect to a mastectomy shall provide an insured or enrollee who is receiving benefits in connection with a mastectomy and whoelects breast reconstru…

A. A health insurance issuer offering group or individual health insurance coverage may not: 1. Deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy solely for the purpose of avoiding the requirements of this Regula…

A health insurance issuer providing group or individual health insurance coverage shall provide notice to the named insured in the case of an individual policy, and to each certificate holder in the case of a group policy, regarding the coverage required by this Regulation. Such …

This Regulation does not apply to any group health insurance coverage in relation to its provision of excepted benefits described in 42 U.S.C. § 300gg-21(c) and (d), and does not apply to any individual health insurance coverage in relation to its provision of expected benefits d…

The effective date of this Regulation shall be thirty (30) days from and after its adoption and filing with the Secretary of State of the State of Mississippi. Notes 19 Miss. Code. R. 3-13.08 Miss. Code Ann. § 25-43-3.113 (Rev. 2010)

This Regulation shall be known and may be cited as the Managed Care Plan Network Adequacy Regulation and is promulgated by the Commissioner of Insurance pursuant to the authority granted to him by Title 83, the Mississippi Insurance Code; the requirements of Miss. Code Ann. § 25-…

The purpose of this Regulation is to establish standards for the creation and maintenance of networks by health carriers and to ensure adequate access to covered persons in a managed care plan. This Regulation enhances the adequacy, accessibility, and quality of health care servi…

For purposes of this Regulation: A. "Commissioner" means the Commissioner of Insurance. B. "Covered benefits" or "benefits" means those health care services to which a covered person is entitled under the terms of a health benefit plan. C. "Covered person" means a policyholder, s…

This Regulation shall apply to all health carriers that offer managed care plans; provided, however, the Regulation shall not apply to the Mississippi State Employee Health Plan or to any managed care plan regulated by the Mississippi Division of Medicaid, or to any self-insured …

A. A health earner providing a managed care plan shall maintain a network that is sufficient in numbers and types of participating providers to ensure that all covered services to covered persons will be accessible without unreasonable delay. In the case of emergency facility ser…

A health carrier offering a managed care plan shall meet the following requirements contained in this section, in addition to any other requirements required under Mississippi law. A. A health carrier shall establish a mechanism by which the participating provider will be notifie…

A contract between a health carrier and an intermediary shall satisfy all the requirements contained in this section. A. Intermediaries and participating providers with whom they contract shall comply with all the applicable requirements of Rule 14.06. B. A health carrier's statu…

A health carrier may designate material submitted to the Commissioner pursuant to this regulation as confidential and exempt from disclosure to the public under the Mississippi Public Records Act if the health carrier deems the material to meet the criteria set forth in Miss. Cod…

A. The execution of a contract by a health carrier shall not relieve the health carrier of its liability to any person with whom it has contracted for the provision of services, nor of its responsibility for compliance with the law or applicable regulations. B. All contracts shal…

The Commissioner may retain outside consultants to assist the Commissioner for determining compliance with this regulation, and the fees and costs of such consultants paid by the health carrier to the consultants pursuant to Miss. Code Ann. § 83-41-407. A violation of this Regula…

if any provision of this Regulation, or the application of the provision to any person or circumstance shall be held invalid, the remainder of the Regulation, and the application of the provision to persons or circumstances other than those to which it is held invalid, shall not …

This Regulation shall be effective thirty (30) days after final adoption with the Office of the Secretary of State. All provider and intermediary contracts in effect on the effective date of this Regulation, or which are issued or put in force on or after the effective date of th…

The purpose of this Regulation is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination, as defined …

For purposes of this Regulation: A. "Adverse determination" means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed a…

A. Except as provided in subsection B, this Regulation shall apply to all health carriers. B. The provisions of this Regulation shall not apply to a policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, de…

A. 1. A health carrier shall notify the covered person in writing of the covered person's right to request an external review to be conducted pursuant to Rule 15.07, Rule 15.08 or Rule 15.09 of this Regulation and include the appropriate statements and information set forth in su…

A. 1. Except for a request for an expedited external review as set forth Rule 15.08 of this Regulation, all requests for external review shall be made in writing to the Commissioner. 2. The External Review Request Form, attached hereto as Rule 15.21 -Appendix "B", meets the form …

A. 1. Except as provided in subsection B, a request for an external review pursuant to Rule 15.07, Rule 15.08 or Rule 15.09 of this Regulation shall not be made until the covered person has exhausted the health carrier's internal grievance process. 2. A covered person shall be co…

A. 1. Within four (4) months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to Rule 15.04 of this Regulation, a covered person or the covered person's authorized representative may file a request for an external review wi…

A. Except as provided in subsection F, a covered person or the covered person's authorized representative may make a request for an expedited external review with the Commissioner at the time the covered person receives: 1. An adverse determination if: a. The adverse determinatio…

A. 1. Within four (4) months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to Rule 15.04 of this Regulation that involves a denial of coverage based on a determination that the health care service or treatment recommende…

A. An external review decision is binding on the health carrier except to the extent the health carrier has other remedies available under applicable State law. B. An external review decision is binding on the covered person except to the extent the covered person has other remed…

A. The Commissioner shall approve independent review organizations eligible to be assigned to conduct external reviews under this Regulation. B. In order to be eligible for approval by the Commissioner under this section to conduct external reviews under this Regulation an indepe…

A. To be approved under Rule 15.11 of this Regulation to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review pro…

No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions perfor…

A. 1. An independent review organization assigned pursuant to Rule 15.07, Rule 15.08 or Rule 15.09 of this Regulation to conduct an external review shall maintain written records in the aggregate by State and by health carrier on all requests for external review for which it cond…

The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the cost of the independent review organization for conducting the external review. Notes 19 Miss. Code. R. 3-15.15 Miss. Code Ann. § 83-5-1 (Rev. 2011); P…

A. 1. Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage it provides to covered persons. 2. The disclosure required by paragraph (1) sha…

Any forms issued by a health carrier to the covered person or the covered person's authorized representative pursuant to this regulation must be filed with and approved by the Commissioner prior to use. Notes 19 Miss. Code. R. 3-15.17 Miss. Code Ann. § 83-5-1 (Rev. 2011); Public …

If any provision of this Regulation, or the application of the provision to any person or circumstance shall be held invalid, the remainder of the Regulation, and the application of the provision to persons or circumstances other than those to which it is held invalid, shall not …

This Regulation shall be effective on January 1, 2013. Notes 19 Miss. Code. R. 3-15.19 Miss. Code Ann. § 83-5-1 (Rev. 2011); Public Law 111-148 -Mar. 23, 2010 (Patient Protection and Affordable Care Act) Adopted 4/15/2015

NOTICE OF APPEAL RIGHTS You have a right to appeal any decision we make that denies payment on your claim or your request for coverage of a health care service or treatment. You may request more explanation when your claim or request for coverage of a health care service or treat…

This EXTERNAL REVIEW REQUEST FORM must be filed with Mississippi Insurance Department within FOUR (4) MONTHS after receipt from your insurer of a denial of payment on a claim or request for coverage of a health care service or treatment. Click Here To View Image Click Here To Vie…

Click Here To View Image Click Here To View Image Notes 19 Miss. Code. R. 3-15.22 Miss. Code Ann. § 83-5-1 (Rev. 2011); Public Law 111-148 -Mar. 23, 2010 (Patient Protection and Affordable Care Act) Adopted 4/15/2015