Appeals of Determinations Not to Certify

Appeals of Determinations Not to Certify (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 patient. The procedures for appeals shall include, at a minimum, the following statement: a. Any person aggrieved by a final decision of the department or a private review agent in a contested case under this act shall have the right of judicial appeal to the chancery court of the county of the residence of the aggrieved person. b. Notwithstanding any provision of this act, the insured shall have the express right to pursue any legal remedies he may have in a court of competent jurisdiction. (2) If a prior review agent has clear and convincing evidence that a health care professional or health care provider has knowingly and willingly submitted false or fraudulent requests for prior authorization to the health insurance issuer, the issuer shall notify and provide that the information in the manner as provided in Subsection (3) of this Section to the Commissioner of Insurance. (3) If a health insurance issuer intends either to implement a new prior authorization requirement or restriction or amend an existing requirement or restriction, the health insurance issuer shall provide contracted health care professionals and contracted health care providers of enrollees written notice of the new or amended requirement or amendment no less than sixty (60) days before the requirement or restriction is implemented. Written notice may take the form of a conspicuous notice posted on the health insurance issuer’s public website or portal for contracted health care professionals and contracted health care providers. A health insurance issuer shall provide email notices to health care professionals or health care providers if the health care professional or health care provider has requested to receive the notice through email. The health insurance issuer shall ensure that the new or amended requirement is not implemented unless the health insurance issuer’s website has been updated to reflect the new or amended requirement or restriction. Written notice of a new, amended, or restricted prior authorization requirement, as required by Miss. Code Ann. §83-5-909(6), may be provided less than sixty (60) days in advance if a health insurance issuer determines and contemporaneously notifies the department in writing and submitted to priorauthoriztion.notice@mid.ms.gov : (a) The health insurance issuer has identified fraudulent or abusive practices related to the health care service; (b) The health care service is unavailable or scarce which necessitates the use of an alternative health care service; (c) The health care service is newly introduced to the health care market and a delay in providing coverage for the health care service and would not be in the best interests of enrollees; (d) The health care service is the subject of a clinical trial authorized by the United States Food and Drug Administration; or (e) Changes to the health care service or its availability are otherwise required by law to be made by the health insurance issuer in less than sixty (60) days.