Division of Medicaid

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. 209-1.50 Miss. Code Ann. § 43-13-121

A. Medicaid defines a humidifier, heated or non-heated, as a device used to increase the moisture content of the air. B. Medicaid covers humidifiers for all beneficiaries when ordered by a physician, medically necessary and prior authorized by the Utilization Management and Quali…

A. Medicaid defines pressure reducing support surfaces as surfaces designed for beneficiaries with limited or no mobility who are bed confined most or all of the day and prone to developing pressure ulcers. B. Medicaid covers pressure reducing support surfaces for all eligible be…

A. The Division of Medicaid does not cover items or services through durable medical equipment (DME) and medical appliance program that do not meet: 1. The definition of DME and/or medical appliances, 2. Medical necessity or standard of care criteria, 3. Healthcare Common Procedu…

Medicaid covers durable medical equipment not covered by Medicare if the reason for the Medicare denial is other than for medical necessity. For dual eligible beneficiaries covered by both Medicare and Medicaid, Medicaid reimburses the Medicare deductible and co-insurance for tho…

Medicaid covers the duplication of DME on an individual basis only. Medicaid covers the duplication of DME item(s) that are not portable, not mobile, or the size/weight of the item is such that daily or frequent transportation is not feasible. Notes 23 Miss. Code. R. 209-1.8 Miss…

A. The Division of Medicaid requires that the beneficiary and/or the legal guardian, with medically appropriate assistance from the ordering physician, have freedom of choice to select the durable medical equipment (DME) provider and must be informed of all DME, medical appliance…

A. The Division of Medicaid defines medical supplies as medically necessary health care related items that are consumable or disposable or cannot withstand repeated use by more than one individual, that are required to address an individual medical disability, illness or injury. …

The Division of Medicaid covers the following medical supplies when they are medically necessary and considered standard care for the treatment of a beneficiary's medical condition and dispensed in quantities that meet a beneficiary's medical needs without excessive utilization, …

Oral Hygiene supplies that include tooth brushes, dental floss, toothpaste, toothettes, lemon glycerin swabs and other non-specific oral hygiene items. Notes 23 Miss. Code. R. 209-2.3 Miss. Code Ann. §§ 43-13-117, 43-13-121. Deleted Miss. Admin. Code Part 209, Rule 2.3.B., eff. 0…

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. 209-2.4 Miss. Code Ann. § 43-13-121. Amended 7/…

A. The Division of Medicaid may operate a diabetic supply rebate program in coordination with the Sovereign States Drug Consortium.1. Diabetic supplies included in the rebate program are listed on the Preferred Diabetic Supply List located on the Division of Medicaid's website. 2…

A. Medicaid considers an Ambulatory Surgical Center (ASC) a publicly, or privately, owned institution not considered a part of a hospital, in accordance with its function. B. Ambulatory surgical centers must be operated by its own organized medical and administrative staff primar…

A. Add-on codes are defined as procedures performed in addition to the primary service/procedure and are never reported as a stand-alone code. Add-on codes describe additional intra-service work associated with the primary procedure. B. Ambulatory surgery is defined as surgical p…

Ambulatory surgical centers must satisfy all requirements set forth in Part 200, Chapter 4, Rule 4.8 in addition to the following provider type specific requirements listed below: A. National Provider Identifier (NPI), verification from National Plan and Provider Enumeration Syst…

A. The Ambulatory Surgical Center (ASC) must have procedures for obtaining routine and emergency laboratory and radiology services from Medicare-approved facilities. The ASC, when contracting for those lab, x-ray and hospital services which directly relate to the surgical procedu…

Non-covered services and procedures as outlined in Part 200, Chapter 2, Rule 2.2 performed in an Ambulatory Surgical Center are subject to Medicaid rules for reimbursement. Notes 23 Miss. Code. R. 210-1.5 Miss. Code Ann. § 43-13-121; 42 CFR § 416

A. Mississippi Medicaid Ambulatory Surgical Care (ASC) rates are updated October 1 of each year based on eighty percent (80%) of the Medicare ASC Payment System rate in effect July 1 of that year set by the Center for Medicare and Medicaid Services (CMS). B. Reimbursement is in a…

The physician and ASC must maintain auditable records that will substantiate the services provided. The ASC must maintain a medical record for each patient. Medical records must include at least the following: A. Patient identification, B. Significant medical history and results …

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. 210-1.8 Miss. Code Ann. § 43-13-121

The Division of Medicaid defines: A. A Federally Qualified Health Center (FQHC) encounter as a face-to-face visit for the provision of services provided by physicians, physician assistants, nurse practitioners, nurse midwives, dentists, optometrists, clinical psychologists, Licen…

A. To participate as a Federally Qualified Health Center (FQHC) in the Medicaid program, an organization must be approved by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) as an FQHC. B. FQHC providers must comply with the requiremen…

A. The Division of Medicaid limits reimbursement to a Federally Qualified Health Center (FQHC) to no more than four (4) encounters per beneficiary per day, provided that each encounter represents a different type of visit, as the Division of Medicaid only reimburses for one (1) m…

A. The Division of Medicaid does not reimburse an FQHC for services when performed in an inpatient or outpatient hospital setting. If a physician is employed by an FQHC and provides services in a hospital setting, the FQHC is prohibited from billing for these services. The physic…

The Division of Medicaid reimburses Federally Qualified Health Center (FQHC) providers at a prospective payment system (PPS) rate per encounter and/or an alternative payment methodology (APM). A. The Division of Medicaid uses the PPS methodology for reimbursement to FQHC provider…

The Division of Medicaid requires Federally Qualified Health Centers (FQHCs) to maintain auditable records that substantiate the services provided in accordance with Miss. Admin. Code Title 23, Part 200, Rule 1.3. At a minimum, the records must contain the following on each benef…

The Division of Medicaid defines: A. Rural Health Clinic as a provider that has been designated a Rural Health Clinic by the Centers for Medicare and Medicaid Services (CMS) and for purposes of this policy includes both provider-based rural health clinics and freestanding rural h…

A. To participate as a Rural Health Clinic (RHC) in the Medicaid program, an organization must be approved by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) as an RHC. B. RHC providers must comply with the requirements set forth in M…

A. The Division of Medicaid limits reimbursement to a Rural Health Clinic (RHC) to no more than four (4) encounters per beneficiary per day, provided that each encounter represents a different type of visit, as the Division of Medicaid only reimburses for one (1) medically necess…

A. The Division of Medicaid does not reimburse an RHC for services when performed in an inpatient or outpatient hospital setting. If a physician is employed by an RHC and provides services in a hospital setting, the RHC is prohibited from billing for these services. The physician…

The Division of Medicaid reimburses Rural Health Clinic (RHC) providers at a prospective payment system (PPS) rate per encounter and/or alternative payment methodology (APM). A. The Division of Medicaid uses the PPS methodology for reimbursement to RHC providers per encounter as …

The Division of Medicaid requires Rural Health Clinics (RHCs) to maintain auditable records that will substantiate the services provided in accordance with Miss. Admin. Code Title 23, Part 200, Rule 1.3. At a minimum, the records must contain the following on each patient: A. Dat…

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. 212-1.7 Miss. Code Ann. §§ 43-13-117, 43-13-121…

Providers of physical therapy must comply with the requirements set forth in Part 200, Chapter 4, Rule 4.8 in addition to the provider specific requirements outlined below: A. National Provider Identifier (NPI), verification from National Plan and Provider Enumeration System (NPP…

Medicaid defines maintenance therapy as activities that preserve the patient's present level of function and prevent regression of that function. Maintenance programs do not require the professional skills of a licensed therapy provider, are not considered medically necessary, an…

A. Physical therapy provider records must document and maintain records in accordance with requirements set forth in Miss. Admin. Code Part 200, Rule 1.3. B. Required documentation by a servicing physical therapy provider includes, but is not limited to, the following: 1. Benefic…

A. Medicaid covers therapy services not covered by Medicare if the reason for the Medicare denial is other than for medical necessity. The therapy services must be pre-certified through the UM/QIO. B. Beneficiaries cannot receive services under both programs simultaneously. Notes…

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. 213-1.13 Miss. Code Ann. § 43-13-121

A. Medicaid defines physical therapy services as medically prescribed services designed to develop, improve or restore neuro-muscular or sensory-motor function, relieve pain, or control postural deviations. Services are concerned with the prevention of disability, and rehabilitat…

A. The Division of Medicaid covers physical 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 Divi…

The Division of Medicaid does not cover or reimburse for physical 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 dated …

Notes 23 Miss. Code. R. 213-1.5 Miss. Code Ann. § 43-13-121; 42 CFR 440.110; 42 CFR 410.60 Reserved 1/1/2016

A. Medicaid requires prior authorization/precertification for certain outpatient therapy services. 1. Prior authorization/precertification for therapy services is conducted through the Utilization Management and Quality Improvement Organization (UM/QIO). 2. Failure to obtain prio…

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

A. Medicaid requires a Certificate of Medical Necessity for Initial Referral/Orders 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 require…

Medicaid does not cover therapy services when documentation supports that the beneficiary: A. Has not reached therapy goals and is unable to participate and/or benefit from skilled intervention, B. Refuses to participate, or C. Is otherwise noncompliant with the therapy regimen. …

Providers of occupational therapy must comply with the requirements set forth in Part 200, Chapter 4, Rule 4.8 in addition to the provider specific requirements outlined below: A. National Provider Identifier (NPI), verification from National Plan and Provider Enumeration System …