Division of Medicaid

A. The Division of Medicaid covers occupational therapy services in the outpatient setting when medically necessary, ordered by a physician, physician assistant or nurse practitioner, and prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the …

The Division of Medicaid does not cover or reimburse for occupational therapy services in the outpatient setting when: A. Services are not certified/ordered by a physician, physician assistant, or nurse practitioner, B. The plan of care (POC) has not been approved, signed, and da…

A. The UM/QIO will determine medical necessity, the types of therapy services, and the number of units reasonably necessary to treat the beneficiary's condition. The frequency of visits provided by the therapist must match the Plan of Care signed by the prescribing provider. B. P…

A. Medicaid provides benefits for therapy services that are medically necessary, as certified by the prescribing provider. B. The prescribing provider must complete a Certificate of Medical Necessity for Initial Referral/Orders form and submit it to the therapist prior to therapy…

A. A Certificate of Medical Necessity for Initial Referral/Orders must be completed by the prescribing provider, and it must be received by the therapist prior to performing the initial evaluation. The evaluation does not require prior authorization. B. Before therapy is initiate…

A. Maintenance programs do not require the professional skills of a licensed therapy provider, are not considered medically necessary, and are not covered by Medicaid. B. Maintenance programs must be planned and taught before the end of active therapy treatment so that the benefi…

A. Occupational therapy providers must document and maintain records in accordance with the requirements set forth in Part 200, Chapter 1, Rule 1.3. B. Required documentation by an occupational therapy servicing provider includes, but is not limited to, the following: 1. Benefici…

Providers of speech-language pathology must comply with the requirements set forth in Part 200, Rule 4.8 in addition the provider type specific requirements outlined below. Therapy providers wishing to enroll as group providers must adhere to the enrollment requirements in Part 2…

A. Medicaid covers therapy services not covered by Medicare if the reason for the Medicare denial is other than for medical necessity. The therapy service must be prior authorization/precertified through the UM/QIO. B. Beneficiaries cannot receive services under both programs sim…

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization. Notes 23 Miss. Code. R. 213-3.11 Miss. Code Ann. § 43-13-121

A. Medicaid defines speech therapy services as medically prescribed services necessary for the diagnosis and treatment of communication impairment and/or swallowing disorder that has occurred due to disease, trauma or congenital anomaly. B. Medicaid defines a speech-language path…

A. The Division of Medicaid covers speech-language pathology and audiology services in the outpatient setting when medically necessary, ordered by a physician, physician assistant or nurse practitioner, for the diagnosis and treatment of a communication impairment and/or swallowi…

The Division of Medicaid does not cover or reimburse for speech-language pathology or audiology services in the outpatient setting when: A. Services are not certified/ordered by a physician, physician assistant, or nurse practitioner, B. The plan of care (POC) has not been approv…

A. Medicaid requires prior authorization/precertification of certain outpatient therapy services. Prior authorization/precertification for therapy services is conducted through the Utilization Management and Quality Improvement Organization (UM/QIO) Failure to obtain prior author…

A. Medicaid covers therapy services that are medically necessary, as certified by the prescribing provider. Medicaid defines prescribing provider as a state-licensed physician, nurse practitioner, or physician assistant who refers the beneficiary for therapy services. B. The pres…

A. Medicaid requires a Certificate of Medical Necessity for Initial Referral/Orders must be completed by the prescribing provider, and it must be received by the therapist prior to performing the initial evaluation. The evaluation does not require prior authorization. B. Medicaid…

A. Maintenance programs do not require the professional skills of a licensed therapy provider, are not considered medically necessary, and are not covered by Medicaid. Such services include, but are not limited to, the following: 1. Services related to the general welfare of the …

A. Speech therapy providers must document and maintain records in accordance with the requirements set forth in Part 200, Chapter 1, Rule 1.3. B. Required documentation by servicing speech therapy provider includes, but is not limited to, the following: 1. Beneficiary demographic…

A. Reconsideration Process - The beneficiary, therapy provider, or prescribing provider is afforded the right to appeal a utilization review denial to the UM/QIO through the reconsideration process set forth by the UM/QIO. B. Administrative Appeal - Disagreement with the UM/QIO r…

A. Pharmacists must comply with the requirements set forth in Part 200, Chapter 4, Rule 4.8 for all providers in addition to the provider type specific requirements that follow: 1. National Provider Identifier (NPI), verification from National Plan and Provider Enumeration System…

A. The Division of Medicaid recommends that prescribers use the drugs on the Preferred Drug List (PDL).1. The PDL is defined as a list of drugs reviewed and proposed by the Pharmacy and Therapeutics (P&T) Committee, a group of physicians, pharmacists, nurse practitioners, and/or …

The Division of Medicaid covers all FDA approved smoking cessation OTC and prescription drugs and nicotine replacement products when used to promote smoking cessation, except dual eligible as Part D will cover. Notes 23 Miss. Code. R. 214-1.11 Miss. Code Ann § 43-13-121. Effectiv…

A. The pharmacy must obtain the signature of beneficiary or his/her representative signature and their relationship to the beneficiary for each prescription received with the exception of beneficiaries living in long-term care facilities, i.e. nursing facilities, intermediate car…

A. The Division of Medicaid utilizes a quality assurance program, Drug Utilization Review (DUR), to:1. Promote patient safety by an increased review and awareness of outpatient prescribed drugs including drug appropriateness, 2. Enhance and improve the quality of pharmaceutical c…

All drugs, as defined by the Veterans Health Care Act of 1992 Title VI, purchased by an in house pharmacy of a Federally Qualified Health Center (FQHC) at a discounted price must be reported on the cost report and are reimbursed through the core services encounter rate and not bi…

Providers participating in the 340B program must adhere to all the provisions in Miss. Admin. Code Part 200, Chapter 4, Rule 4.10. Notes 23 Miss. Code. R. 214-1.15 Sec. 340B of the Public Health Service Act (Pub. L. 102-585), as amended by the Patient Protection and Affordable Ca…

A. The Division of Medicaid defines Clinician Administered Drugs and Implantable Drug System Devices (CADDs) as certain physician-administered drugs, with limited distribution or limited access for beneficiaries and administered in an appropriate clinical setting, which may be bi…

A. The Division of Medicaid covers the following pharmacy services including, but not limited to: 1. Prescription drug coverage which includes all legend prescription drugs manufactured by a company that has signed a drug rebate agreement with certain specific Centers for Medicar…

A. The Division of Medicaid does not cover pharmacy benefits for full benefit, dual eligible individuals who are entitled to receive Medicare benefits under Part A, B, or C, except for drugs in the Medicare excluded categories. B. Medicaid excluded or otherwise restricted drugs i…

A. The Division of Medicaid requires prior authorization of certain covered drugs to ensure use as approved by the Food and Drug Administration (FDA) for specific medical conditions.1. Prior authorization of drugs must be obtained from the Division of Medicaid's Pharmacy Prior Au…

The Division of Medicaid reimburses for certain legend and non-legend drugs: A. As authorized under the State Plan, B. Prescribed by a Mississippi Medicaid enrolled prescribing provider licensed to prescribe drugs, and C. Dispensed by a Mississippi Medicaid enrolled pharmacy in a…

A. Pharmacists in the legal employ of the pharmacy provider or under the personal direction of a pharmacist employed by the pharmacy provider must submit claims for services rendered. Prescriptions must be dispensed at the provider's actual physical location of the pharmacy. B. F…

A. A written, faxed, e-prescribed, or telephoned prescription may be refilled, in compliance with the prescriber's order, up to a limit of eleven (11) times per year, if compliant with state and/or federal regulations and guidelines. Additionally, the following are applicable: 1.…

Mississippi law requires that the Division of Medicaid does not reimburse for a brand name drug if an equally effective generic equivalent is available and the generic equivalent is the least expensive. A. Generic drugs classified as non-preferred by the Division of Medicaid requ…

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Miss. Admin. Code, Part 223, without regard to service limitations and with prior authorization. Notes 23 Miss. Code. R. 214-1.9 Miss. Code Ann. § 43-13-121.…

The Division of Medicaid defines: A. Home health services as skilled nursing visits, home health aide visits, and durable medical equipment, supplies and appliances provided to a beneficiary:1. At the beneficiary's place of residence, 2. Ordered by the beneficiary's physician or …

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23, without regard to service limitations and with prior authorization. Notes 23 Miss. Code. R. 215-1.10 Miss. Code Ann. § 43-13-121

Home health providers, including out-of-state providers, must satisfy all requirements set forth in Part 200, Rule 4.8 in addition to the following provider type specific requirements: A. National Provider Identifier (NPI), verification from National Plan and Provider Enumeration…

A. The Division of Medicaid covers the following home health services: 1. Skilled nursing visits. a) Intermittent or part-time skilled nursing services must be provided during the visit by a registered nurse (RN) or a licensed practical nurse (LPN) under the supervision of a RN e…

The Division of Medicaid does not cover: A. Home health services provided to a beneficiary who can receive the services in an outpatient setting including, but not limited to:1. Outpatient hospital, 2. Free-standing clinic, or 3. Nursing facility. B. Services that are not medical…

A. In order to receive reimbursement from the Division of Medicaid for the face-to-face encounter, the encounter must be conducted by an enrolled Medicaid provider. B. The Division of Medicaid reimburses for home health services based on reasonable cost determined in accordance w…

A. The Division of Medicaid requires the home health agency to maintain auditable records that substantiate the services provided and include, at a minimum, the following in each beneficiary's record verifying services provided by the home health agency are medically necessary [R…

A. The Division of Medicaid covers all medically necessary services for beneficiaries who qualify for the federally mandated Early, Periodic Screening, Diagnosis and Treatment (EPSDT) program without regard to service limitations and with prior authorization. B. Physical therapy,…

Beneficiaries eligible for Medicare and Medicaid must not receive home health visits under both programs simultaneously. Refer to Part 200, Chapter 2, Rule 2.3. A. If Medicare does not cover home health nurse visits, physical therapy visits, or speech therapy visits because skill…

A. The Division of Medicaid covers home health agency reimbursement for covered services based on reasonable cost which is determined in accordance with the Mississippi Medicaid Home Health Reimbursement Plan and Title XVIII (Medicare) principles of reimbursement, except when Med…

Freestanding or hospital-based kidney dialysis centers must satisfy all requirements set forth in Miss. Admin. Code, Part 200, Chapter 4, Rule 4.8, in addition to the following provider type specific requirements: A. National Provider Identifier (NPI), verification from National …

A. The Division of Medicaid covers:1. Hemodialysis, 2. Peritoneal dialysis, 3. Continuous Ambulatory Peritoneal Dialysis (CAPD), and 4. Continuous Cyclic Peritoneal Dialysis (CCPD). B. Prior authorization is not required for dialysis services. C. The Division of Medicaid covers:1…