Division of Medicaid

A. The applicant or beneficiary has the right to appeal a local hearing decision by requesting a state hearing; however, the state hearing request must be made within fifteen (15) days of the postmark date of the local hearing decision. This means the state hearing request must b…

A. Disability or Blindness Denials. 1. An appeal related to a disability or blindness denial must be resolved through a state hearing. Procedures for filing a state hearing appeal are detailed in Rules 2.5 through 2.8 of this chapter and should be followed. 2. After the state hea…

A. A state hearing is assigned to an impartial hearing officer. The hearing officer has not been involved in any way with the action or decision prior to being assigned the appeal at the state level. The hearing officer: 1. Reviews the local office's action; 2. Schedules the hear…

A. One or both members of a couple may file a hearing request either jointly or separately when they are denied benefits and that denial arises from the same issue. B. If a joint hearing is held, both members of the couple may present evidence at the hearing, and the agency's dec…

The Division of Medicaid defines: A. Case Record as all documents relevant to the administration of an appeal, including but not limited to all correspondence, applications, medical records and decisions, and past appeals. B. Course of Treatment as a planned program of one or mor…

A. A group hearing can be held for multiple applicants or beneficiaries under the following circumstances: 1. The Division of Medicaid may consolidate the cases and conduct a single group hearing when the only issue involved is a single law or agency rule common to all members of…

When an applicant/beneficiary or representative requests a hearing within the Advance Notice Period, benefits must be continued or reinstated to the benefit level in effect prior to the planned adverse action, if a timely request is filed. A. Timely Request for Continuation of Be…

A. Appeal Procedure for Waivers Administered by the Mississippi Department of Rehabilitative Services (MDRS). 1. MDRS administers benefits for the following waivers:a) Independent Living (IL) Waiver, and b) Traumatic Brain Injury/Spinal Cord Injury (TBI/SCI) Waiver, 2. A Case Man…

A. The Division of Medicaid provides an opportunity to contest any adverse decisions through an appeal and fair hearing process, and notifies applicants, beneficiaries and/or their legal representatives of their Medicaid appeal rights. The following categories have appeal process…

A. The applicant or beneficiary, or their representative may request to present an appeal through a local hearing, a state hearing, or both. B. There are two instances in which a local hearing is not permitted, and the applicant or beneficiary must request relief directly through…

Appeals regarding eligibility must be filed with the agency through which the applicant/beneficiary first applied. Agencies include: A. Mississippi Division of Medicaid, 1. The Mississippi Division of Medicaid is responsible for making eligibility determinations for the following…

A. The Division of Medicaid provides beneficiaries the opportunity to request a fair hearing in order to appeal decisions of:1. Eligibility, 2. Denial, 3. Termination, 4. Suspension, or 5. Reduction of Medicaid covered services. B. If a decision is made to reduce, deny, suspend, …

A. All hearing requests may initially be written, oral, or made in-person at a regional office. B. Written Hearing Requests 1. A simple statement requesting a hearing that is signed by the applicant/beneficiary or the applicant/beneficiary's legal representative is sufficient. 2.…

A. The applicant or beneficiary has thirty (30) days from the postmark date of the appropriate notice to request either a local or state hearing. This thirty (30) day filing period may be extended if the applicant or beneficiary can show good cause, as determined by the Division …

The Division of Medicaid must take final administrative action on a hearing, whether state and/or local, within ninety (90) days of the date of the initial request for a hearing. Notes 23 Miss. Code. R. 300-2.9 42 C.F.R. Part 431 Subpart E; Miss. Code Ann. §§ 43-13-116, 43-13-117…

The Mississippi Division of Medicaid conducts provider hearings for the following reasons: A. The provider is dissatisfied with a Final Agency Action of the Division of Medicaid relating to:1. Disallowances, 2. Withholding of funds resulting from overpayments, 3. Suspension of pa…

The Division of Medicaid defines: A. Administrative Hearing as a trial-like proceeding before the Division of Medicaid at which evidence and testimony may be offered. B. Hearing Officer as the presiding officer appointed by the Executive Director or the Executive Director's desig…

A. Within thirty (30) calendar days after a Final Agency Action has been made, the provider may request a formal administrative hearing. B. Appeal requests must: 1. Be written, 2. Explain the facts that support the provider's position, 3. Supply reasons the provider purports to h…

A. The administrative hearing shall be conducted in an informal manner but consistent with courtroom practices and procedures. B. Location of Hearing. 1. The administrative hearing will be held at the Division of Medicaid's central office, unless otherwise designated. 2. Hearings…

A. After the hearing has concluded, the Hearing Officer shall issue a recommendation with respect to the Final Agency Action. The standard of review to be applied by the Hearing Officer is whether the Final Agency Action was: 1. Unsupported by substantial evidence, 2. Arbitrary a…

A. Appeal of a final administrative decision must be filed in a court of proper jurisdiction within sixty (60) days from the date of notice. The Final Decision will be mailed to the provider by certified mail sent to the proper address of the provider on file with the Division of…

A. A provider or the Division may request a consolidated hearing when two or more matters arise from the same fact pattern or involve the same issue of law. The administrative Hearing Officer may grant or deny a party's request for consolidation. B. The Hearing Officer must take …

Any matter involving a provider requiring an administrative hearing or an appeal not otherwise defined within these rules will be allowed as outlined in this chapter. If specific time frames of the matter relating to the requesting, granting, and concluding of the hearing are con…

A. Administrative Review for a Denied Claim is defined as a review of a claim denied for timely filing that is conducted by the Division's Office of Provider Solutions. B. Final Administrative Decision is defined as the final decision regarding an Administrative Review for a Clai…

A. The Provider may not seek relief from the Division for a claim denied due to an error within the timely processing period until the provider exhausts the applicable process for the type of error as detailed below. 1. Fiscal Agent Error a) When a claim is denied due to Fiscal A…

A. The Division of Medicaid, the Mississippi Department of Education (MDE) and individual schools share in the responsibility for promoting access to healthcare for students in the public school system, preventing costly or long term healthcare problems for at-risk students, and …

State school districts that participate in the School Based Administrative Claiming (SBAC) program must meet the following requirements: A. Have a signed agreement with the Mississippi Department of Education (MDE), B. Attend staff training conducted by MDE, C. Keep time studies …

A. The Division of Medicaid will establish and maintain a quality assurance process which ensures the quality management of the program. It is necessary to monitor the SBAC program in order to assure that Medicaid dollars are utilized to make Administrative Claiming available to …

Reimbursement under the SBAC program is paid from those invoices filed during the quarter directly following the quarter of billing, for reported allowable reimbursable activities, in accordance with the Mississippi School Based Administrative Claiming Guide (as approved by CMS),…

A. The Division of Medicaid defines Beneficiary Health Management (BHM) as the program implemented by the Division of Medicaid to: 1. Closely monitor program usage and to identify beneficiaries who may be potentially over utilizing or misusing their Medicaid services and benefits…

A. The Division of Medicaid's Office of Program Integrity:1. Manages the Beneficiary Health Management (BHM) program, 2. Screens beneficiaries against criteria designed to identify drug seeking behavior and inappropriate use of prescription drugs, and 3. Reviews claims and pharma…

The Beneficiary Health Management (BHM) program may include physician only, pharmacy only, or physician and pharmacy providers. Notes 23 Miss. Code. R. 302-2.3 Miss. Code Ann. §§ 43-13-117, 43-13-121. Adopted 2/1/2019

A. The Division of Medicaid will notify the beneficiary in writing prior to the imposing of the restrictions of: 1. Its intent to enroll them in the Beneficiary Health Management (BHM) program, and 2. Their opportunity for a hearing as outlined in Miss. Admin. Code Part 300. B. T…

A. The beneficiary has ten (10) days to choose his/her Beneficiary Health Management (BHM) designated physician and/or pharmacy provider(s) from the date of receipt of the notification letter. B. The Division of Medicaid will designate a BHM physician and/or pharmacy provider for…

The Division of Medicaid locks-in a beneficiary in the Beneficiary Health Management (BHM) program for a period of twelve (12) months with ongoing reviews to monitor patterns of care. A. Beneficiaries in the BHM program are allowed two (2) counseling sessions in addition to State…

The Division of Medicaid may exclude a beneficiary from the Beneficiary Health Management (BHM) program if the beneficiary: A. Has one (1) of the following diagnoses including, but not limited to: 1. Cancer, 2. Sickle cell anemia, or 3. Burns. B. Is enrolled in hospice care. Note…

A. The Division of Medicaid reimburses for: 1. Office visits only with the Beneficiary Health Management (BHM) designated physician, 2. Drugs prescribed only by the BHM designated physician, by the consultant physician, or by an emergency department physician, and 3. Drugs dispen…

A. General: It is the mission of the Division of Medicaid to ensure compliance, efficiency, and accountability within the Mississippi Medicaid program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implemen…

A. General 1. Section 6032 of the federal Deficit Reduction Act (DRA) of 2005 (Public Law 109-171) set forth administrative requirements which impacts entities receiving annual Medicaid payments of at least $5,000,000. The DRA requires certain governmental, for-profit and non-pro…

A. Abuse is defined as beneficiary practices that result in unnecessary cost to the Medicaid program and/or provider practices that are inconsistent with sound fiscal, business, or medical practices that result in: 1. An unnecessary cost to the Mississippi Medicaid Program, 2. Re…

A. The Division of Medicaid investigates suspected cases of fraud, waste, and abuse using methods that: 1. Do not infringe on the legal rights of persons involved, and 2. Afford due process of law to individuals under investigations. B. The Division of Medicaid must make a formal…

A. Providers must notify the Division of Medicaid's Office of Program Integrity in writing within thirty (30) calendar days of the discovery of any overpayments. 1. Any self-disclosure of overpayments submitted to the Division of Medicaid must include the following information: a…

A. Mississippi Medicaid providers must ensure that the services or items provided to beneficiaries are: 1. Provided economically, to the extent medically necessary, 2. Of a quality that meets professionally recognized standards of health care, 3. Supported by the appropriate docu…

A. The Division of Medicaid will identify the cause of any improper payments due to an error in the beneficiary's eligibility information including, but not limited to, incorrect income or deductions, and take corrective action. B. All underpayments are corrected upon discovery: …

A. A beneficiary must cooperate with Medicaid Eligibility Quality Control (MEQC) reviews. B. If a beneficiary fails to cooperate with MEQC reviews and an investigator is unable to obtain information needed to complete a review, the case will be referred back to the regional offic…

The Division of Medicaid defines: A. Third party as any individual, entity or program that is, or maybe, liable to pay all, or part of the expenditures for medical assistance furnished under the State Plan. B. Cost Avoidance as a method of avoiding payment of Medicaid claims when…

A. Medicaid providers must:1. Identify and report any third party source to the Division of Medicaid. 2. Cooperate with the Division of Medicaid in the recovery of payments from the third party source. Providers will be held liable, to the extent of the Division of Medicaid's pay…