Mississippi Administrative Code

Unless otherwise defined herein, any term defined in Miss. Code Ann. §§ 83-5-901 through 83-5-937 shall have the same meaning in this Regulation. Notes 19 Miss. Code. R. 3-19.03 Miss. Code Ann. §§ 83-5-901 through 83-5-937. Adopted 1/1/2025

This Regulation shall apply to every health insurance issuer and all health benefit plans, as both terms are defined in Miss. Code Ann. § 83-9-6.3, and all private review agents and utilization review plans, as both terms are defined in Miss. Code Ann. § 41-83-1, with the excepti…

(1) Adverse determination: A determination by a health insurance issuer that, based on the information provided, a request for a benefit under the health insurance issuer's health benefit plan upon application of any utilization review technique does not meet the health insurance…

(1) A private review agent who approves or denies payment or who recommends approval or denial of payment for hospital or medical services or whose review results in approval or denial of payment for hospital or medical services on a case by case basis, may not conduct utilizatio…

(1) A certificate expires on the second anniversary of its effective date unless certification has been renewed for a two (2) year term. (2) Before the certification expires, the certified private review agent may renew its certification for an additional two (2) year term, if th…

(1) The Commissioner shall deny a certificate to an applicant if the Department finds that the applicant does not: a. Have available the services of a sufficient number of registered nurses, that are supervised by appropriate physicians to efficiently carry out its utilization re…

(1) Responsibility for Obtaining Certificationa. In the absence of any contractual agreement to the contrary, the enrollee is responsible for notifying the private review agent in a timely manner and obtaining certification for health care services, if required by the health bene…

(1) Each private review agent shall have in place procedures for appeals of determinations not to certify an admission, procedure, service or extension of stay. The right to appeal shall be available to the patient or enrollee, and to the attending physician on behalf of the pati…

(1) Utilization review of prior authorizations in nonurgent circumstances. If a health insurance issuer requires prior authorization of a health care service, the health insurance issuer must make an approval or adverse determination and notify the enrollee, the enrollee's health…

To facilitate an Urgent Prior Authorization request in a timely manner as required by statute and this Rule, a health insurance issuer must establish a policy to ensure Health Care Professionals, defined as a physician, registered professional nurse or other individual appropriat…

When a provider or facility makes a request for prior authorization, should a health insurance issuer make an adverse determination, the health insurance issuer shall include in writing the following in the notification to the enrollee, the enrollee's health care professional, an…

1) A health insurance issuer must ensure that all appeals are reviewed by a physician when the request is by a physician or a representative of a physician. The physician must:a. Possess a current and valid nonrestricted license to practice medicine in any United States jurisdict…

Notwithstanding language to the contrary elsewhere contained herein, if a licensed physician certifies in writing to an insurer within seventy-two (72) hours of an admission that the insured person admitted was in need of immediate hospital care for emergency services, such shall…

(1) A prior authorization approval shall be valid for the lesser of six (6) months after the date the health care professional or provider receives the prior authorization approval or the length of treatment as determined by the patient's health care professional or the renewal o…

(1) If a health insurance issuer requires a prior authorization for a recurring health care service or maintenance medication for the treatment of a chronic or long-term condition, including, but not limited to, chemotherapy for the treatment of cancer, the approval shall remain …

(1) On receipt of information documenting a prior authorization approval from the enrollee or from the enrollee's health care professional or health care provider, a health insurance issuer shall honor a prior authorization granted to an enrollee from a previous health insurance …

(1) A health insurance issuer may not revoke or further limit, condition or restrict a previously issued prior authorization approval while it remains valid under this act. (2) Notwithstanding any other provision of law, if a claim is properly coded and submitted timely to a heal…

(1) By January 1, 2025, all health insurance issuer or designee utilization review organization shall make available a standardized electronic prior authorization request transaction process using an internet webpage, internet webpage portal, or similar electronic, internet, and …

(1) By June 1, 2025, and each June 1 after that date, a health insurance issuer shall report to the department, on a form issued by the department, the following aggregated trend data, de-identified of protected health information, related to the insurer's practices and experienc…

Pursuant to Miss. Code Ann. § 83-5-909(7), health insurance issuers using prior authorization shall make statistics available regarding prior authorization approvals and denials on their website in a readily accessible format. Following each calendar year, the statistics must be …

The Department may issue a cease-and-desist order or require a private review agent or health insurance issuer to submit a plan of correction for violation of Miss. Code Ann. §§ 83-5-901 through 83-5-937. The Department may impose upon a private review agent, health benefit plan …

(1) A failure by a health insurance issuer to comply with the deadlines and other requirements specified in this act shall result in any health care services subject to review to be automatically deemed authorized by the health insurance issuer or its contracted private review ag…

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 and after January 1, 2025. Notes 19 Miss. Code. R. 3-19.26 Miss. Code Ann. § 25-43-3.108 (Rev. 2022); Miss. Code Ann. §§ 83-5-901 through 83-5-937. Adopted 1/1/2025

MEMORANDUM TO ALL COMPANIES WRITING HEALTH AND ACCIDENT INSURANCE: The Department is being deluged with letters from insureds requesting assistance in the payment of claims. A great number of the letters from the insureds state that an "agent" told them to write the Department an…

WHEREAS, a marked degree of confusion exists in this state by reason of various interpretations relative to use of the terms "non-cancellable" and guaranteed renewable"insurance, it is deemed in the public interest for the Mississippi Insurance Department toadopt the interpretati…

Section 83-9-5(7), Mississippi Code of 1972, Annotated, provides that the Commissioner of Insurance may make reasonable rules and regulations concerning the procedure for the filing or submission of accident and sickness insurance policies Pursuant to such authority, every insura…

The purpose of these rules is to assure truthful and adequate disclosure of all material and relevant information in the advertising of accident and sickness insurance. This purpose is intended to be accomplished by the establishment of, and adherence to, certain minimum standard…

A. These rules shall apply to any accident and sickness insurance "advertisement", as that term is hereinafter defined, intended for presentation, distribution or dissemination in this State when such presentation, distribution or dissemination is made either directly or indirect…

A. An advertisement for the purpose of these rules shall include: 1. Printed and published material, audio visual material, and descriptive literature of an insurer used in direct mail, newspapers, magazines, radio scripts, TV scripts, billboards and similar displays; and 2. Desc…

All information required to be disclosed by these rules shall be set out conspicuously and in close conjunction with the statements to which such information relates or under appropriate captions of such prominence that it shall not be minimized, rendered obscure or presented in …

A. The format and content of an advertisement of an accident or sickness insurance policy shall be sufficiently complete and clear to avoid deception or the capacity or tendency to mislead or deceive. Whether an advertisement has a capacity or tendency to mislead or deceive shall…

A. Deceptive Words, Phrases Or Illustrations Prohibited.1. No advertisement shall omit information or use word, phrases, statements, references or illustrations if the omission of such information or use of such words, phrases, statements, references or illustrations has the capa…

When an advertisement which is an invitation to contract refers to either a dollar amount or a period of time for which any benefit is payable, or the cost of the policy, or specific policy benefit, or the loss for which such benefit is payable, it shall disclose the provisions r…

A. Testimonials used in advertisements must be genuine, represent the current opinion of the author, be applicable to the policy advertised and be accurately reproduce. The insurer, in using a testimonial, makes as its own all of the statements contained herein, and the advertise…

A. An advertisement relating to the dollar amounts of claims paid, the number of persons insured, or similar statistical information relating to any insurer or policy shall not use irrelevant facts, and shall not be used unless it accurately reflects all of the relevant facts. Su…

A. When a choice of the amount of benefits is referred to, an advertisement which is an invitation to contract shall disclose that the amount of benefits provided depends upon the plan selected and that the premium will vary with the amount of the benefits selected. B. When an ad…

An advertisement shall not directly or indirectly make unfair or incomplete comparisons of policies or benefits or comparisons of non-comparable policies of other insurers, and shall not disparage competitors, their policies, services or business methods, and shall not disparage …

A. An advertisement which is intended to be seen or heard beyond the limits of the jurisdiction in which the insurer is licensed shall not imply licensing beyond those limits. B. An advertisement shall not create the impression directly or indirectly that the insurer, its financi…

The name of the actual insurer [and] shall be stated in all of its advertisements. The form number or numbers of the policy advertised shall be stated in an advertisement which is an invitation to contract. An advertisement shall not use a trade name, any insurance group designat…

An advertisement of a particular policy shall not state or imply that prospective insureds become group or quasi-group members covered under a group policy and as such enjoy special rates or underwriting privileges, unless such is the fact. Notes 19 Miss. Code. R. 3-5.14 Miss Cod…

A. 1. An advertisement of an individual policy shall not directly or by implication represent that a contract or combination of contracts is an introductory , initial or special offer, or that applicants will receive substantial advantages not available at a later date, or that t…

An advertisement shall not contain statements which are untrue in fact, or by implication misleading, with respect to the assets, corporate structure, financial standing, age or relative position of the insurer in the insurance business. An advertisement shall not contain a recom…

A. Advertising File Each insurer shall maintain at its home or principle office a complete file containing every printed, published or prepared advertisement of its individual policies and typical printed, published or prepared advertisements of its blanket, franchise and group p…

If any section or portion of a section of these rules, or the applicability thereof to any person or circumstance is held invalid by a court, the remainder of the rules or the applicability of such provision to other persons or circumstances, shall not be affected thereby. Notes …

The methods of interpretation and guidelines in construing the foregoing rules and regulations shall so far as applicable be those adopted by the National Association of Insurance commissioners, as shown in Volume 1, 1972 Proceedings of the National Association of Insurance Commi…

These rules shall take effect and be in force from and after January 1, 1975. Promulgated and Adopted, this the 25th day of November, 1974. Notes 19 Miss. Code. R. 3-5.20 Miss Code Ann § 25-43-3.113 (Rev. 2010)