Notification for Adverse Determinations / Form

Notification for Adverse Determinations / Form 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, and the enrollee's health care provider: (1) The reasons for the adverse determination and related evidence-based criteria, including a description of any missing or insufficient documentation; (2) The right to appeal the adverse determination; (3) Instructions on how to file the appeal; and (4) Additional documentation necessary to support the appeal. A decision may be provided orally, but subsequent written notice must also be provided within twenty-four (24) hours of the oral decision. A denial must include the department and credentials of the individual who has the authorizing authority to approve or deny the request, including a phone number to contact the authorizing authority and a notice regarding the enrollee’s appeal rights and process. A health insurance issuer, when sending a notice to a covered person of a denial of a request for prior authorization made under this section, shall include with such notice the following statement in bold and in twelve (12) point font: THE STATEMENT BELOW IS REQUIRED BY MISSISSIPPI INSURANCE DEPARTMENT REGULATION ACTIONS YOU CAN TAKE AND HOW TO GET HELP You, or someone on your behalf, recently requested approval from your health insurance plan for a health care service or item. Your health insurance plan denied the request. You have the right to ask your health insurance plan to change this decision. This is called an internal appeal. If the request is not approved after an internal appeal, your request may be eligible for a review by an independent third party. This is called an external review. The independent third party may change your health insurance plan’s decision, or it may confirm your health insurance plan’s decision. Please read carefully the information your health insurance plan has provided with this insert. This information explains the reason(s) for the health insurance plan’s decision, as well as how to ask for an internal appeal or external review, including any deadlines and timing. You should also feel free to contact your health insurance plan or the Mississippi Insurance Department to help you understand your rights and answer any questions. Contact information for both your health insurance plan and the Department is included in the information your health insurance plan has provided.