Mississippi Administrative Code

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

Click Here To View Image Notes 19 Miss. Code. R. 3-15.23 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

This regulation is adopted and promulgated pursuant to the authority granted by Miss. Code Ann. Section 83-5-1 (Rev. 2011), and in accordance with the provisions of the Administrative Procedures Act found at Miss Code Ann. 25-43-1, et seq., and the Mississippi Insurance Departmen…

The Centers for Medicare and Medicaid Services (CMS) issued a Bulletin entitled Form and Manner of Notices when Discontinuing or Renewing a Product in the Small Group or Individual Market on September 2, 2014. Under 45 CFR Sections 146.152, 147.106, and 148.122 an issuer that dis…

In accordance with CMS guidance, the Mississippi Department of Insurance ("Department") has created a form entitled "Renewal Form for Individual Products" ("Form"), which is found in Rule 16.06 of this Regulation. Issuers may begin using this form immediately, without the necessi…

If any provision of this regulation, or the application thereof to any person or circumstance, is held invalid, such determination shall not affect other provisions or applications of this regulation which can be given effect without the invalid provision or application, and to t…

This Regulation shall be effective thirty (30) days after final adoption with the Office of the Secretary of State. Notes 19 Miss. Code. R. 3-16.05 Miss. Code Ann. §§ 25-43-3.108; 25-43-3.112; 83-5-1 (Rev. 2011). Adopted 4/22/2015

RENEWAL FORM FOR INDIVIDUAL PRODUCTS OFFERED OUTSIDE OF THE MARKETPLACE Important: We are continuing to Offer Your Health Coverage. Dear (First Name of Subscriber): Your health insurance coverage is coming up for renewal. On (Date of Renewal), you will be automatically re-enrolle…

This regulation is adopted and promulgated pursuant to the authority granted by Miss. Code Ann. § 83-5-1, §§ 83-9-1 et seq., §§ 83-41-401 et seq. and in accordance with the provisions of the Administrative Procedures Act found at Miss Code Ann. § 25-43-1 et seq. Notes 19 Miss. Co…

A. Purpose. The purpose of this regulation is to establish requirements for companies who offer fully insured, comprehensive, major medical health insurance products on the remittance of certain claims data to large employer groups as defined by Mississippi Insurance Department B…

A. Upon request by a large employer group ("group") or the group's agent or broker, the group's health carrier shall make available the currently available summary health information, aggregate paid claim, and premium data accumulated for the current and the immediately preceding…

If any section or portion of a section of this regulation or the application thereof to any person or circumstance is held by a court to be invalid, such invalidity shall not affect any other provision of that section or application of this regulation which can be given effect wi…

This regulation shall become effective thirty (30) days after filing for final adoption with the Office of the Secretary of State. Notes 19 Miss. Code. R. 3-17.05 Miss Code Ann.§ 25-43-3.112; § 25-43-3.113 (Rev. 2018). Adopted 1/1/2021

This Regulation shall be known and may be cited as the Managed Care Plan Certification 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. § 25-43-…

The purpose of this Regulation is to establish a process for certifying managed care plans pursuant to the provisions of Miss. Code Ann. § 83-41-401 et seq., also known as the Mississippi Patient Protection Act of 1995. Additionally, it furthers the goals of the Managed Care Plan…

For purposes of this Regulation, the term "managed care entities" as used herein, shall include a "health carrier" as that term is defined in Rule 14.03 of Title 19, Part 3, Chapter 14. Any term defined in Rule 14.03 of Title 19, Part 3, Chapter 14 will have the same meaning in t…

This Regulation shall apply to all managed care plans, managed care entities and managed care contractors; 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…

A. Beginning June 1, 2025, managed care entities shall file with the Commissioner sample contract forms proposed for use with its participating providers and intermediaries. B. By June 1 of each calendar year, managed care entities shall submit to the Commissioner, in an electron…

A. Based on the information managed care entities must submit pursuant to this Regulation and the Managed Care Network Adequacy Regulation, the Commissioner shall review such information and if found sufficient, the Commissioner shall issue an annual certification of each managed…

The Commissioner, at any time, may review a managed care entity's compliance with this Regulation or the Managed Care Plan Network Adequacy Regulation, request information from the managed care entity necessary to investigate the managed care entity's compliance, and order the co…

A managed care entity or managed care contractor 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…

A violation of this Regulation shall be subject to the penalty provisions set forth in Miss. Code Ann. § 83-5-17, as well as other penalty provisions under applicable law. Notes 19 Miss. Code. R. 3-18.09 Miss. Code Ann. § 83-5-17; § 83-41-405; § 83-41-413 (Rev. 2022) Adopted 8/12…

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 …