Mississippi Administrative Code

Medicaid requires prior authorization for the extraction of a supernumerary tooth. Notes 23 Miss. Code. R. 204-2.2 Miss. Code Ann. § 43-13-121

A. The Division of Medicaid defines an impacted tooth as one where its eruption is partially or wholly obstructed by bone, soft tissue or other teeth. B. The Division of Medicaid covers surgical extractions and removal of impacted teeth. C. The Division of Medicaid does not cover…

The Division of Medicaid covers alveoloplasty as a separate procedure from extractions or in conjunction with extractions when there is a need for significant bone re-contouring in the quadrant to prepare the ridge for a prosthetic appliance if there: A. Are three (3) or more too…

Medicaid does not cover for the surgical removal of residual tooth roots with an extraction separately. The appropriate code for surgical removal of residual tooth roots (cutting procedures) must be used to bill the surgical removal of residual roots when a tooth has been broken …

Medicaid covers complicated suturing only in instances of trauma where simple sutures cannot be placed or simple suturing is not possible. Medicaid does not pay separately when done with extractions of unerupted teeth or when the dentist creates the flap or incision. Medicaid req…

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. 204-2.7 Miss. Code Ann. § 43-13-121

A. Admission to hospice and subsequent election periods must be prior authorized through a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designated entity. B. The hospice provider must provide all required services to meet the need…

A. The hospice benefit must be used simultaneously under Medicare and Medicaid with Medicare providing primary coverage for dual eligible beneficiaries. B. The Division of Medicaid requires the hospice provider to submit the Notice of Hospice Election or Discharge for Dual Eligib…

A. Prior authorization is required for the initial and all subsequent hospice election periods. B. All prior authorization requests must be submitted within ten (10) calendar days of the effective date of the election period and must include the following: 1. For the initial nine…

Providers of hospice must comply with all federal, state, and local laws and regulations related to the health and safety of beneficiaries and: A. Meet the conditions of participation set forth in 42 C.F.R. Part 418, Subpart D, B. Be licensed and certified for participation by th…

A. Only a Medicaid enrolled medical doctor or doctor of osteopathy can certify or recertify a terminal illness. B. A beneficiary who reaches a point of stability and no longer meets the definition of terminally ill must not be recertified and must return to Medicaid benefits, if …

A. A beneficiary must meet eligibility requirements for hospice care services. For the duration of an election of hospice care services, a beneficiary waives all rights to Medicaid State Plan services for treatment related to the terminal illness and related conditions. In order …

A. The hospice provider must ensure each beneficiary has an individualized written plan of care (POC) established by the hospice interdisciplinary team/interdisciplinary group (IDT/IDG) in collaboration with the attending physician, if any, beneficiary, family and/or primary care…

The Division of Medicaid covers hospice services in accordance with the hospice plan of care (POC), when prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designated entity and provided in a manner that is consist…

A. The hospice provider must: 1. Provide transportation for medical services relating to the terminal illness and related conditions after the admission to the hospice, 2. Provide transportation from the hospital to the beneficiary's residence or to a freestanding hospice facilit…

A. A hospice provider must obtain written certification/recertification of terminal illness before billing for hospice services. B. The Division of Medicaid reimburses hospice providers at one (1) of the four (4) following predetermined rates for each day that the beneficiary is …

A. The hospice provider must maintain medical records for each beneficiary at the hospice site which corresponds to the address associated with the provider license and Division of Medicaid provider number and must include, but not limited to, the following: 1. The Division of Me…

A. All providers of community mental health services must:1. Provide proof of certification by the Mississippi Department of Mental Health (MDMH), professional license, or certification and/or license from the appropriate agency as required by the Division of Medicaid, 2. Provide…

The Division of Medicaid defines: A. Assessment as obtaining from the beneficiary, beneficiary's family or others involved in the beneficiary's care, the beneficiary's family background/ educational/vocational achievement, presenting problem(s), problem history, history of previo…

A. The Division of Medicaid covers four (4) medically necessary mental health assessments by a non-physician per fiscal year when:1. Completed during the intake process and/or when there is a need for reassessment. 2. Provided by a staff member who holds a master's degree and pro…

A. The Division of Medicaid does not cover community mental health services that: 1. Are not medically necessary, 2. Are not prior authorized by the Division of Medicaid, Utilization Management/Quality Improvement Organization (UM/QIO) or designee, if required, and 3. Are not par…

A. The Division of Medicaid reimburses for covered mental health services according to a statewide uniform fee schedule. B. Reimbursement for physician services provided outside of a Community or Private Mental health center are subject to the limits described in Miss. Admin. Cod…

A. All services must be documented on a treatment plan and approved, signed and dated by a licensed practitioner operating within their scope of practice. B. The following must be documented in the beneficiary's case record for each service provided: 1. Type of service provided, …

A. A Pre-Admission Screening and Resident Review (PASRR) Level I must be performed prior to admission to a Medicaid certified nursing facility (NF), except for the exclusions listed under Miss. Admin. Code Part 207, Rule 1.2., to: 1. Assess the person's clinical eligibility and n…

A. A Pre-Admission Screening and Resident Review (PASRR) Level I is not required when a person is: 1. Admitted to a nursing facility (NF) when the person was discharged from an acute care hospitalization directly into a NF for continued treatment of a condition for a period of le…

The Pre-Admission Screening Resident Review (PASRR) Level I must be completed by the following qualified individuals: A. Physician, B. Nurse Practitioner or Registered Nurse, C. Licensed Social Worker, D. Rehabilitation Counselor, E. Designee by facility/setting, or F. Certified …

A. A person must be advised of all identified placement options funded by the Division of Medicaid as part of ensuring that an informed choice is made regardless of where a person applies for services. Medicaid beneficiaries have the right to freedom of choice of providers for Me…

Notes 23 Miss. Code. R. 207-1.5 Miss. Code Ann. § 43-13-121 Reserved 6/1/2019

Persons have the right to appeal long-term care eligibility denials. [Refer to Miss. Admin. Code Part 300] Notes 23 Miss. Code. R. 207-1.6 Miss. Code Ann. §§ 43-13-116, 43-13-117, 43-13-121. Revised eff. 06/01/19 Amended 6/1/2019

A. The Division of Medicaid will execute a provider agreement with a nursing facility (NF) only when the Mississippi Department of Health (MSDH) or Centers for Medicare and Medicaid Services (CMS) has certified the NF has met all participation requirements in accordance with fede…

A. The Division of Medicaid utilizes a resource utilization grouper-version 4 (RUG-IV) fortyeight (48) group model for case mix calculation for reimbursement. 1. Each of the forty-eight (48) resident classifications as well as the default classification is assigned case mix weigh…

A. Basic Requirements 1. The facility must, upon written authorization by the resident, accept responsibility for holding, safeguarding and accounting for the resident's personal funds. The facility may make arrangements with a federally or state insured banking institution to pr…

A. Nurse Aide Training and Testing Reimbursement1. The Division of Medicaid uses the direct reimbursement method for nurse aide training and testing expenses incurred by nursing facilities. 2. Reasonable cost of training and competency testing of nurse aides in order to meet the …

A. Public access to records maintained by the Medicaid agency is mandated. The exceptions to public access are those records which are exempt as confidential or privileged. B. Beneficiary-Specific Information will only be released by the Medicaid agency when the requirements of f…

A. Beneficiaries in nursing facilities may obtain medications from pharmacies holding retail, closed door or institutional permits. Nursing facility (NF) residents may receive unlimited prescriptions per month if the medication orders, signed by the prescribing provider, are docu…

A. The Division of Medicaid defines ventilator dependent care (VDC) as mechanical ventilation for life support designed to replace and/or support normal ventilatory lung function. B. Effective January 1, 2015, the Division of Medicaid provides an established reimbursement per die…

A. All nursing facilities are required to provide rehabilitation services for residents. Requirements include physical, occupational and speech-language pathology therapies. Medicaid, consistent with third party liability rules, is obligated to cover these services. B. Prior auth…

A. Feeding Assistant Reimbursement1. The Division of Medicaid uses the direct reimbursement method for feeding assistant training expenses incurred by nursing facilities. Reasonable costs of training of feeding assistants in order to meet the requirements necessary for the feedin…

A. The Division of Medicaid defines a wheelchair as a seating system that is designed to increase the mobility of residents who would otherwise be restricted by inability to ambulate or transfer from one place to another. B. The Division of Medicaid defines an individualized, res…

A. Nursing facilities must comply with all federal, state, local, and Mississippi State Department of Health (MSDH) emergency preparedness requirements, and must establish and maintain an emergency preparedness program in accordance with 42 C.F.R. § 483.73. B. Nursing facilities …

Nursing facility providers 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 Provider Identifier (NPI), verification from National Plan and Provider Enumeration System (NPPES). B.…

A. A nursing facility must notify the resident and the resident's guardian or legal representative of a facility initiated transfer or discharge. 1. The notice of transfer or discharge must be given at least thirty (30) calendar days prior to the transfer or discharge unless: a) …

A. The Division of Medicaid will use one (1) or more of the following remedies when deemed appropriate by the Centers for Medicare and Medicaid Services (CMS) or the Division of Medicaid based on results of surveys conducted by the Mississippi State Department of Health, Bureau o…

A state is not required to pay for any expenses related to payment for deductibles, coinsurance, or co-payments for Medicare cost sharing for dually eligibles that exceed what the state's Medicaid program would have paid for such service for a beneficiary who is not a dually elig…

A. Participating Mississippi nursing facilities must prepare and submit a Medicaid cost report for reimbursement. 1. All cost reports are due by the end of the fifth (5th) calendar month following the reporting period. 2. Failure to file a cost report by the due date or the exten…

A. The nursing facility must provide and pay for all items and services required to meet the needs of a resident. B. Items and services covered by Medicare or any other third party must be billed to Medicare or the other third party and are considered non-allowable on the cost re…

A. A Pre-Admission Screening and Resident Review (PASRR) Level I must be completed to determine clinical eligibility for persons seeking admission to a Division of Medicaid certified nursing facility (NF) regardless of payment source except for the exclusions listed in Miss. Admi…