23 Miss. Code. R. 220-1.2

Current through October 18, 2024

Rule 23-220-1.2 - Prior Authorization

A. Effective July 1, 2013, prior authorization is required by the radiology Utilization Management/Quality Improvement Organization (UM/QIO) for medical necessity and appropriateness of the service for the following advanced imaging procedures:

1. Computed Tomography (CT) Scans and Computed Tomography Angiography (CTA),

2. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA),

3. Positron Emission Tomography (PET) Scans, and

4. Nuclear Cardiac Imaging Studies.

B. Prior Authorization for the advanced imaging procedures listed in Rule 1.2.A. is required in all settings except in an:

1. Inpatient hospital,

2. Emergency room, or

3. Outpatient hospital twenty-three (23) hour observation period.

C. The prior authorization request must be submitted by either the ordering or the rendering provider.

1. The provider must submit documentation indicating medical necessity and appropriateness of the service to the radiology UM/QIO, including, but not limited to, the:

a) Results of a recent clinical evaluation,

b) Diagnosis or clinical condition which the imaging evaluation is being ordered,

c) Treatment history related to the stated diagnosis or clinical condition,

d) Treatment plan related to the stated diagnosis or clinical condition, and

e) Previous imaging results related to the stated diagnosis or clinical condition.

2. Medical necessity and appropriateness of the service is based on nationally-accepted guidelines and radiology protocols based on peer reviewed literature for urgent, emergent and non-emergent services including, but not limited to, the:

a) Division of Medicaid's radiology UM/QIO Clinical Decision Support Tool for Advanced Diagnostic Imaging,

b) American College of Radiology's Appropriateness Criteria,

c) American Academy of Neurology,

d) American Academy of Orthopedic Surgeons,

e) American College of Cardiology,

f) American Heart Association, and/or

g) National Comprehensive Cancer Care Network.

D. Prior authorization must be received by the provider before the procedure is rendered except in medically urgent situations.

E. In the event of a medical emergent condition or situation a retrospective review may be requested.

1. The request must be received by the radiology UM/QIO within three (3) business days from the date of service.

2. The Division of Medicaid defines a medical emergent condition or situation as one which:

a) The patient faces immediate risk of loss of life or limb,

b) Could seriously jeopardize the life or health of the beneficiary or their ability to regain maximum function based on a prudent layperson's judgment, or

c) In the opinion of a practitioner with knowledge of the beneficiary's medical condition, would subject the beneficiary to severe pain that cannot be adequately managed without the requested advanced imaging procedure.

23 Miss. Code. R. 220-1.2

Miss. Code Ann. § 43-13-121, 42 CFR §§431.10(e), 440.230(d).

Added Rule 1.2.C. eff. 01/01/2014, Added to correspond with approved SPA 2013-007 (eff. 07/01/2013) eff. 07/01/2013.