Mississippi Administrative Code

A. For admissions dated October 1, 2012, and after, the Division of Medicaid reimburses all hospitals a per stay rate based on All Patient Refined Diagnosis Related Groups (APR-DRGs). APR-DRGs classify each case based on information contained on the inpatient Medicaid claim inclu…

A. Facilities must submit a Uniform Cost Report to Medicaid following the close of their Medicare Title XVIII approved year end. Any deviations to the reporting year, such as a Medicare approved change in fiscal year end should be submitted to Division of Medicaid in writing. In …

A. Under Diagnosis Related Groups (DRG)-based payment, hospitals cannot split bill inpatient hospital Medicaid claims when a stay crosses a state fiscal year end, cost report year end, or under any other circumstance unless otherwise specified by the Division of Medicaid. B. For …

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of this Title, without regard to service limitations and with prior authorization. Notes 23 Miss. Code. R. 202-1.17 Miss. Code Ann. § 43-13-121

A. The Division of Medicaid defines Review for Medical Necessity and/or Independent Verification and Validation (IV&V) as the Utilization Management/Quality Improvement Organization (UM/QIO) or Division of Medicaid, or designee, review of services of Medicaid beneficiaries in the…

Hospital providers, including psychiatric hospitals and swing bed providers applying for enrollment into the Medicaid program must satisfy all requirements set forth in Part 200, Chapter 4, Rule 4.8 in addition to the following provider type specific requirements: A. National Pro…

A. Requirement 1. Prior authorization is required from the appropriate Utilization Management/Quality Improvement Organization (UM/QIO) for all inpatient hospital admissions except for vaginal deliveries with a length of stay of two (2) days or less, cesarean deliveries with a le…

A. Covered inpatient services include:1. Ancillary services. 2. Drugs, excluding take home drugs. 3. Supplies. 4. Oxygen. 5. Durable Medical Equipment. 6. The cost of implantable programmable baclofen drug pumps used to treat spasticity which are implanted in an inpatient hospita…

A. Services provided in a geriatric psychiatric unit of a hospital. B. Services rendered to a Medicaid beneficiary and billed by a physician employed by or contracted with the hospital. C. Elective cancellation of procedures not related to the beneficiary's medical condition. 1. …

Refer to Chapter 5, Rule 5.1 Notes 23 Miss. Code. R. 202-1.6

Refer to Chapter 5, Rule 5.2 Notes 23 Miss. Code. R. 202-1.7

Refer to Chapter 5, Rule 5.3 and Rule 5.6 Notes 23 Miss. Code. R. 202-1.8

Refer to Chapter 5, Rule 5.4 Notes 23 Miss. Code. R. 202-1.9

Medicaid provides financial assistance for outpatient hospital services. An outpatient is a person who is being provided services by a hospital other than on an inpatient basis or for whom laboratory or radiology services are performed for a referring physician. All rules set for…

The Division of Medicaid defines Phase II Cardiac Rehabilitation services as a physician supervised program designed to recondition the cardiovascular system and restore beneficiaries with cardiovascular heart disease to their optimal functional status including their physiologic…

Refer to Part 200, Chapter 5, Rule 5.6 Notes 23 Miss. Code. R. 202-2.11 42 CFR §410.141; Miss. Code Ann. §§ 43-13-117, 43-13-121. Adopted 4/1/2015 Amended 12/1/2015

A. The Division of Medicaid defines a provider-based entity as a hospital-based physician clinic that meets the Centers for Medicare and Medicaid Services (CMS) requirements to be considered provider-based. B. A hospital cannot bill a hospital clinic evaluation and management cod…

A. The Division of Medicaid covers outpatient hospital services provided by a licensed hospital in hospital outpatient departments to a beneficiary by or under the direction of a physician or dentist which are preventive, diagnostic, therapeutic, rehabilitative or palliative and …

A. Emergency department services, also referred to as emergency room services, are allowed for all beneficiaries without limitations. Emergency department services provided by hospitals, except for Indian Health Services (IHS), are reimbursed using the outpatient prospective paym…

A. The Division of Medicaid defines outpatient hospital observation services as a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, reassessment, and monitoring that are necessary to determine whether a benefici…

Services provided in hospital-based renal dialysis units (RDU) are covered and are not subject to any visit limitations. Notes 23 Miss. Code. R. 202-2.5 Miss. Code Ann. § 43-13-121, 43-13-117(2)

A. Mental health services provided in an outpatient department of a general hospital are covered when:1. Provided by appropriate staff operating within the scope of their practice, 2. Appropriate for the setting according to the licensure of the hospital, 3. Prior authorized by t…

Out-of-state hospitals will be reimbursed using the same methodology as Mississippi hospitals. Notes 23 Miss. Code. R. 202-2.7 Miss. Code Ann. § 43-13-121; § 43-13-117(A)(2)(c); 42 CFR §431.52 9/1/2012

The Division of Medicaid reimburses all outpatient hospital services except for Indian Health Service Facilities, using the outpatient prospective payment system (OPPS) methodology. Notes 23 Miss. Code. R. 202-2.8 42 C.F.R. § 447.321; Miss. Code Ann. §§ 43-13-117, 43-13-121. 9/1/…

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of this Title, without regard to service limitations and with prior authorization. Notes 23 Miss. Code. R. 202-2.9 Miss. Code Ann. § 43-13-121

Swing bed services are extended care services provided in a hospital bed that has been designated as such. Services consist of one or more of the following: A. Skilled nursing care and related services for patients requiring medical or nursing care, B. Rehabilitation services for…

A. The Division of Medicaid requires any hospital certified for participation in the Medicare swing bed program who wants to participate in the Medicaid program to become a provider. A separate provider number from the hospital is required for the swing bed. B. Hospital providers…

A. Swing bed services are covered when all these criteria are met: 1. Services to be furnished are ordered by a physician, are consistent with the nature and severity of the beneficiary's illness or injury, medical needs, and accepted standards of medical practice, and are reason…

A. Individuals who are placed in swing beds in a hospital may have Medicare only, Medicare and Medicaid, or Medicaid only. 1. In all instances where a Medicaid beneficiary is covered by Medicare, Medicare is the primary payer for a swing bed stay. 2. Medicaid covers swing bed car…

A. The Division of Medicaid requires providers of swing bed services to maintain auditable records that substantiate the services provided. Refer to Maintenance of Records Part 200, Ch.1, Rule 1.3. At a minimum, the records must contain the following on each beneficiary: 1. Date …

Providers of transplant services must: A. Complete the requirements for participation in the Mississippi Medicaid program. B. Meet the following facility criteria: 1. Solid organ transplant procedures must be performed in a facility which meets the Centers for Medicare and Medica…

A. Prior authorization is required. B. Heart transplants are covered when all the following criteria are met: 1. Candidate is less than sixty-six (66) years of age. 2. New York Heart Association (NYHA) Class III or IV on maximal medical therapy. 3. Meets transplanting facility's …

A. Prior authorization is required. B. Heart/lung transplants are covered when the following criteria are met: 1. Candidate is less than fifty-six (56) years of age. 2. NYHA Class III or IV with rehabilitation potential. 3. Preserved nutritional state. 4. Meets facility's blood a…

Medicaid covers kidney transplants for all beneficiaries and does not require prior authorization for medical necessity from the UM/QIO. Notes 23 Miss. Code. R. 202-4.12 Miss. Code Ann. § 43-13-121; 42 CFR §482.90104 Revised - 10/01/2012

A. Prior authorization is required. B. Liver transplants are covered when the following criteria are met: 1. Candidate is less than sixty-five (65) years of age. 2. Model for End Stage Liver Disease (MELD) score. 3. Pediatric End Stage Liver Disease (PELD) score. 4. Meets transpl…

A. Prior authorization is required. B. Single lung transplants are covered when the following criteria are met: 1. Candidate is less than sixty-six (66) years of age. 2. NYHA Class III or IV with rehabilitation potential. 3. Preserved nutritional state. 4. Meets facility's blood …

A. Prior Authorization is required. B. Bilateral lung transplants are covered when the following criteria are met: 1. Candidate is less than sixty-one (61) years of age. 2. NYHA Class III or IV with rehabilitation potential. 3. Preserved nutritional state. 4. Meets facility's blo…

A. Medicaid covers bone marrow transplants as noted below and does not require prior authorization for medical necessity from the UM/QIO. B. Bone marrow transplants (BMT), Autologous, Syngeneic, or Allogeneic, are covered for inpatient and outpatient when the following criteria a…

A. No prior authorization is required. B. Peripheral Hematopoietic Stem Cell Transplants (PSCT), Autologous, Syngeneic, or Allogeneic, are covered for inpatient and outpatient when the following criteria are met: 1. Candidate is less than fifty-six (56) years of age for allogenei…

A. Prior authorization is required. B. Medicaid covers small bowel transplants meeting the following criteria for small bowel (or intestinal) transplantation, whether performed as a solitary procedure (SBT); or performed in conjunction with liver (SB/LT); or with stomach, duodenu…

A. The Division of Medicaid covers the following solid organ transplant services when medically necessary and prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designated entity: 1. Single organs: a) Heart, accord…

The Division of Medicaid does not cover the following transplant procedures/services including, but not limited to: A. Transplant procedures/services not medically necessary, B. Transplant procedures/services still in clinical trials and/or investigational or experimental in natu…

A. All fee-for-service (FFS) transplants performed in the state of Mississippi are paid under the Mississippi All Patient Refined-Diagnosis Related Group (APR-DRG) payment methodology, including a policy adjustor. B. All FFS transplants available in Mississippi but performed outs…

A. The Division of Medicaid allows fundraisers to obtain funds needed for transplant costs not covered by the Medicaid program. B. Fundraising criteria includes, but is not limited to, the following: 1. Prior to accepting donations, arrangements must be made with the Division of …

Providers of transplant services must document and maintain records in accordance with requirements set forth in Miss. Admin. Code Part 200, Rule 1.3 on each beneficiary receiving a transplant and must include the following: A. Comprehensive history and physical. B. Treatments re…

The Division of Medicaid pays for all medically necessary services for early and periodic screening, diagnosis, and treatment (EPSDT)-eligible beneficiaries in accordance with Miss. Admin. Code Part 223, without regard to service limitations and with prior authorization. Notes 23…

The Division of Medicaid pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of this Title, without regard to service limitations and with prior authorization. Notes 23 Miss. Code. R. 202-4.8 Miss. Code Ann. § 43-13-121