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CurrentMississippi Division of MedicaidPolicy N/A

Part 200 Chapter 1: General Administrative Rules for Providers

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Governs general administrative requirements for providers participating in the Mississippi Medicaid program, including confidentiality, public access, record maintenance, fundraising, LEP, timely filing, and claims processing rules.

Policy Summary

PayerMississippi Division of Medicaid

PolicyPart 200 Chapter 1: General Administrative Rules for Providers

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2019

Last ReviewOct 1, 2019

Next Review DateN/A

Key ActionSubmit claims no later than 365 days from date of service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365provider claim timely filing limit

5minimum record retention (yrs)

90administrative review window (days)

Nono beneficiary premiums/cost sharing

120maximum retroactive effective date (days)

Coverage, Eligibility, and Service Limits

Claims, records, fundraising, and LEP criteria

Provider claims filing, records, fundraising, and limited English proficiency (LEP) obligations — covered when the following requirements and protections apply:

Providers must submit claims no later than 365 calendar days from the date of service.

Claims submitted by newly enrolled providers must be for services on or after the provider's enrollment effective date and submitted within 365 calendar days from the date of service.

If a Medicare timely claim was filed for the same services, the Division will process the related Medicaid claim within 180 calendar days after receipt of the Medicare disposition.

Clean claim exceptions

Claims with errors originating in the Division's system are considered clean claims and are processed per timeline.

Policy Summary

PayerMississippi Division of Medicaid

PolicyPart 200 Chapter 1: General Administrative Rules for Providers

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2019

Last ReviewOct 1, 2019

Next Review DateN/A

Key ActionSubmit claims no later than 365 days from date of service.

SourceLink

On This Page

Covered services

Medicaid-covered services are organized into federally mandated, state-optional, and waiver categories:

Federally mandated services include EPSDT (Early and Periodic Screening, Diagnostic and Treatment), Expanded EPSDT, Family Planning, FQHC, Home Health, Hospital Inpatient, Hospital Outpatient, Laboratory, Nurse Practitioner, Nursing Facility, Physician, Radiology, Rural Health Clinic, and Transportation (including emergent/non-emergent ambulance, air ambulance & NET).

Optional State-covered services include ambulatory surgical center, chiropractic, community mental health, dental, dialysis, durable medical equipment, eyeglasses and vision, freestanding psychiatric hospital, hearing services and hearing aids, hospice, ICF/MR services, medical supplies, occupational therapy, physical therapy, podiatry, prescription drugs, psychiatric residential treatment facilities, speech therapy, hospital swing bed, and MS State Department of Health Clinic services.

Waivered services include HCBS waivers (Assisted Living, Elderly and Disabled, Independent Living, Intellectual Disabilities/Developmental Disabilities, Traumatic Brain Injury/Spinal Cord Injury), MYPAC, Family Planning Waiver, and the Healthier Mississippi 1115 Waiver.

Non-covered services and exclusions

Services and items expressly not reimbursed by Mississippi Medicaid include (but are not limited to) the following categories:

Examples of non-covered services

Items or services furnished gratuitously with no expectation of payment (e.g., free health department diagnostics, health fair services).
Services provided by legally responsible persons or specified family members except as allowed by State Plan or waiver.
Services denied by a UM/QIO, the Division, or a designated entity.
Investigational or experimental procedures or products (including drugs or devices in clinical trials).
Procedures/products for indications not FDA-approved or without compendia support (examples: physician-administered drugs, implantable drug systems, skin/tissue substitutes, implantable devices).
Cosmetic procedures and certain reconstructive procedures performed primarily to improve appearance.
Infertility treatments (including in-vitro fertilization, reversal of sterilization) and bariatric/obesity surgery.
Routine foot care absent systemic conditions; most prosthetic/orthotic devices except Medicare crossover where allowed.

Non-treatment items

Items not directly related to treatment such as televisions (except as specified), massage, haircuts (except as specified), interest on late pay claims, telephone consultations, missed/cancelled appointments, and wigs.

Non-reimbursable provider conditions

No reimbursement for services ordered/provided by providers excluded by DHHS or Medicare, not currently enrolled as MS Medicaid provider, located outside U.S., unlicensed, or lacking required criminal history checks.

Specified Never Events (wrong surgery/procedure on beneficiary or wrong body part/beneficiary) and most inpatient hospital HCACs identified by Medicare are not covered (limited exceptions described in policy).

No reimbursement for duplicative nursing facility or hospice services when the beneficiary is enrolled in an HCBS waiver or more than one HCBS waiver.

Non-covered services and provider exclusions

Additional provider and service exclusions that render services non-reimbursable include:

Services not specifically listed or defined by the Division are not covered unless part of expanded EPSDT benefits; exclusions listed elsewhere in Title 23, Mississippi Medicaid Bulletins, or other publications also apply.

Providers or entities excluded by federal/state law, those no longer licensed, or otherwise out-of-compliance (see list) are not reimbursable for services provided while excluded or not enrolled.

Eligibility groups covered

Eligibility groups eligible for full Medicaid benefits (Rule 3.1):

The Division covers full Medicaid benefits for specified groups including SSI recipients, certain former SSI recipients, parents/caretaker relatives meeting income limits, pregnant beneficiaries, infants born to Medicaid-eligible mothers, children up to age 19 meeting income limits, children receiving adoption assistance or foster care maintenance, former foster care children under age 26 who received Medicaid at age 18, institutionalized beneficiaries, Katie Beckett group, working disabled, and certain women screened for breast/cervical cancer by MSDH.

The Division covers specified Medicare premiums, cost-sharing or Part C coinsurance/deductibles for eligible categories (e.g., QMB, SLMB, QI) as described in Part 200, Rule 3.1.B.

Beneficiaries enrolled in HCBS waivers receive waiver-specified services as listed in Part 208; Family Planning Waiver and Healthier Mississippi Waiver cover services as specified with stated exclusions.

Cost sharing and billing responsibilities

Beneficiary cost sharing and billing protections — rules on what beneficiaries may and may not be charged:

The Division does not impose premiums or cost sharing on beneficiaries.

Providers who accept Medicaid must bill Medicaid for covered services and accept Medicaid payment as payment in full; beneficiaries may not be billed for Medicaid-covered services except when the person is ineligible or elects to receive and pay for non-covered care.

Beneficiaries may not be held liable for charges when services are later found not medically necessary after qualified peer review, for billed amounts above Medicaid maximum allowable, for claims denied due to provider or Division/fiscal agent errors, for required authorizations not obtained by providers, for completion/submission of the Medicaid claim form, for telephone calls, missed/cancelled appointments, or for costs of copying medical records.

When beneficiaries may be billed

Beneficiaries are responsible for expenses for non-covered services or services received during ineligibility.
Beneficiaries enrolled in managed care who obtain non-authorized services may be responsible for payment as described in Rule 3.9 (e.g., unauthorized ER or specialist visits).
Beneficiary or responsible adult may be billed for services obtained through fraudulent use of a Medicaid card or identity theft.

For dual eligibles, the beneficiary may not be billed the portion of a claim remaining after Medicare and Medicaid have paid.

Dual eligibles payment coordination

Medicare/Medicaid coordination rules for dually eligible beneficiaries and payment responsibilities:

Medicare is the primary payor for beneficiaries with both Medicare and Medicaid; Medicaid pays certain Medicare premiums and cost sharing for eligible categories (e.g., QMB, SLMB, QI) as defined in Rules 3.4 and 3.1.B.

Medicaid processes Part A crossover nursing facility, hospice and home health claims and will not reimburse in aggregate more than what Medicaid would have paid for a non-dual beneficiary; service limits apply and once state service limits are reached no additional payments will be made within the state fiscal year.

All providers must accept Medicare and Medicaid payments as payment in full and are prohibited from billing the beneficiary the balance between provider charge and combined Medicare/Medicaid payments.

For Medicare Part D pharmacy claims, the Division considers the Medicare payment as payment in full for Part D-covered drugs and pharmacy providers must bill Medicare when drugs are covered by Medicare.

Beneficiary charge rules (Rules 3.8 and 3.9)

Beneficiary charge rules (Rules 3.8 and 3.9) — enumerated prohibitions and responsibilities:

Providers who agree to be Medicaid providers must bill Medicaid for covered services and accept Medicaid payment as payment in full; beneficiaries may not be billed for Medicaid covered services except when ineligible or when electing to receive non-covered care and agreeing to pay.

Beneficiaries may not be held liable for services found not medically necessary after qualified peer review, for charges above the Medicaid maximum allowable, for claims denied due to provider or DOM/fiscal agent errors, for telephone calls, missed/cancelled appointments, or for copying medical records.

Beneficiary responsibilities per Rule 3.9

Beneficiaries are responsible for all expenses for non-covered services or services received during a period of ineligibility.
Beneficiaries are responsible for any applicable Medicaid program cost-sharing amounts when applicable.
Beneficiaries who obtain non-authorized services in managed care settings may be responsible for payment as described (e.g., unauthorized ER use or specialist visits).

Beneficiaries or responsible adults may be held accountable for charges arising from fraudulent use of a Medicaid card or beneficiary identity.

Provider conditions of participation (Rule 4.2)

Conditions of provider participation (Rule 4.2) — providers must meet the following to enroll and remain eligible:

Complete and maintain a valid provider enrollment application and provider agreement and keep licensure/certification/current credentials on file; providers with expired or suspended licenses are ineligible effective on the date of action.

Agree to furnish required business transaction documentation to DOM or HHS within 35 days of request and comply with ACA screening procedures including license verifications, database checks, fingerprinting/background checks, and potential site visits; revalidation is required at least once every five years.

Maintain records that fully disclose services rendered and billed, retain records a minimum of five years (longer if required), and provide immediate access to Division staff during regular business hours; follow Part 200 Chapter 1 maintenance rules.

Agree to accept payment per Medicaid reimbursement rules and accept Medicaid payment as payment in full for covered services within service limits (except authorized deductibles/co-insurance/copays); providers may not split services requiring beneficiary payment where Medicaid covers the service.

Comply with disclosure requirements for ownership, control, managing employees and affiliations (use Provider Disclosure Form) and notify DOM within required timeframes; providers convicted of certain felonies or meeting exclusion criteria may be denied enrollment or be terminated.

Provide required enrollment documents (Provider Enrollment Application, Provider Agreement, Direct Deposit, legal name/FED ID matching IRS, EDI agreement if submitting electronically, NPI, civil rights attestation) and supply certain documents within 60 days upon request (e.g., nondiscrimination, LEP, accessibility policies).

Operational and notification obligations

Providers closing or discontinuing services for non-beneficiary reasons must provide 30 days written notice to beneficiaries and DOM and assist with transitions; failure may result in nonpayment for that 30-day period unless prevented by force majeure.
Out-of-state providers may be enrolled under specified conditions (emergency, health risk to travel, needed availability, within specified border mileage) and must submit applications/claims within 120 days for effective date rules.

Change of ownership (CHOW) rules: new owner assumes joint and several liability for amounts due to Medicaid, must notify DOM within 35 days, submit application packet and proof of change, and maintain beneficiary records (specific retention may be extended).

Effective date of provider agreements depends on screening/survey/certification results and may be retroactive up to 120 days in qualifying circumstances (e.g., verified screenings by Medicare contractor or another state's Medicaid/CHIP or CMS deeming/accreditation tie-ins).

Enrollment and billing criteria

Enrollment, billing, and documentation rules — provider enrollment effective dates, required documentation, and specific billing rules (including 340B):

Provider effective dates: effective date may be retroactive up to 120 days in qualifying scenarios (e.g., CMS deeming/accreditation or verified prior screenings); the Division will not pay any provider prior to a valid Medicaid provider agreement.

Providers must maintain current licensure, specialty certificates, permits and attestations; license suspension, revocation or expiration renders the provider ineligible effective the date of action; license renewals provided within one year may be processed to avoid gaps.

Certain providers may continue to receive payment up to 30 days after termination for beneficiaries admitted before termination to permit orderly transfer (inpatient hospital, NF, PRTF, ICF/IDD, home health and hospice services).

Enrollment documentation required: Provider Enrollment Application (signed appropriately), Provider Agreement, Direct Deposit form with acceptable bank documentation, legal name/FEIN or SSN matching IRS records (with IRS confirmation available within 60 days), EDI agreement for electronic submitters, NPI, civil rights compliance attestation, and other disclosures (ownership, affiliations) as required.

Providers must provide certain documents (e.g., nondiscrimination, LEP, accessibility policies) within 60 days upon request and must use the Provider Disclosure Form for specified events (on application, revalidation, within 35 days after change in ownership).

Failure to comply with enrollment documentation and Rule 4.8 terms may result in application rejection, revocation of enrollment, or suspension of claims payment.

340B-specific enrollment and billing: covered entities participating in 340B must elect opt-in/opt-out, register with HRSA, submit the Division's 340B Attestation & Enrollment Form, recertify annually, notify DOM of election changes, dispense 340B drugs only to eligible beneficiaries, bill per Division rules, and submit drug invoices for audit.

340B billing and compliance

340B billing and compliance requirements for covered entities:

Covered entities that elect to opt-in must register with HRSA, complete and submit the Division's 340B Covered Entity Attestation & Provider Enrollment Form, recertify with HRSA annually, and notify the Division in writing of any change in election status.

Opt-out entities must submit the 340B Attestation & Enrollment Form indicating opt-out and must immediately notify the Division of any change to that election.

For POS pharmacy claims, pharmacy providers must bill ingredient cost at the actual acquisition cost (AAC) in effect as of July 1, 2021 (the price paid to wholesaler/manufacturer with no mark-up) plus the applicable professional dispensing fee, and must identify 340B purchased drugs using the appropriate NCPDP field values as defined by the Division.

For medical claims, 340B physician-administered drugs (PAD) must be billed at the same cost in effect for State Fiscal Year 2021 with the appropriate modifier and corresponding HCPCS and NDC to identify the 340B purchased drug.

A contract pharmacy acting as an agent of a 340B covered entity is ineligible to be a freestanding 340B covered entity and cannot dispense and bill the Division for 340B outpatient drugs.

Covered entities must submit drug invoices as required for audit and knowingly making false statements in Medicaid applications may lead to federal and state prosecution.

Medical necessity criteria

Medical necessity standard to determine coverage eligibility:

Medical necessity requires that services be those a prudent provider would provide to evaluate, diagnose, or treat an illness, injury, disease or its symptoms and that they are appropriate and consistent with the treating provider's diagnosis.

Services must be compatible with standards of acceptable medical practice in the United States, provided in a safe, appropriate and cost-effective setting, not primarily custodial or solely for convenience, and not experimental, investigational or cosmetic in nature.

There must be no other effective, more conservative, or substantially less costly treatment or setting available.

Meeting medical necessity does not, by itself, guarantee reimbursement; all program policies, exclusions, limitations and service limits apply.

Wellness coverage

Wellness coverage rules for adults and children (EPSDT):

Annual physical examinations for adults (age 21 and over) are covered and will not be counted toward any physician visit limit; appropriate age-related screenings (cardiovascular, diabetes, Pap/pelvic, mammography starting at age 40, colorectal screening per schedule, prostate screening per age guidelines, bone density per schedule, vision/glaucoma screening, and immunizations) are reimbursed separately when performed.

EPSDT provides mandatory periodic screening, diagnostic and treatment services for children up to age 21; no co-payment applies for beneficiaries under age 18 and EPSDT rules govern screening frequency and coverage.

Medicare's 'Welcome to Medicare' one-time physical may affect Medicaid coverage for dual eligibles whose Medicare Part B coverage begins on or after January 1, 2005; Medicaid will not duplicate benefits for routine annual physicals covered by Medicare until 12 months have elapsed from Medicare Part B effective date.

Annual physicals for school entrance, sports, employment, or for beneficiaries in institutional settings (including nursing facilities or ICF/IID) are not covered.

Tobacco cessation

Tobacco cessation coverage and utilization monitoring:

The Division covers up to 12 in-person or telehealth tobacco cessation counseling sessions per State Fiscal Year when provided by a physician or other licensed practitioner with prescriptive authority within scope of practice.

Tobacco cessation medications covered include over-the-counter nicotine products, legend or prescription nicotine replacement products, bupropion hydrochloride, and varenicline tartrate; a physician's prescription is required for all legend and OTC tobacco cessation medications and each prescription counts toward monthly limits.

The Division will monitor utilization for overutilization or misuse and will contact prescribing physicians for justification when concerning patterns are detected.

Mobile medical units

Mobile medical unit participation and documentation requirements:

Mobile medical units must be owned and operated by a current Medicaid provider that maintains a permanent fixed office location with normal business hours and 24/7 contact availability; units must maintain fixed schedules and have a separate Medicaid provider number.

Mobile units must have qualified clinical staff available during business hours, an emergency follow-up procedure and arrangements with a permanent facility, appropriate communication capabilities, valid driver/vehicle credentials and compliance with vehicle inspection and registration, and ADA accessibility; units must comply with applicable federal/state/local laws for biohazard waste, waste water, safety, sanitation and zoning and have sterilization, potable water, and toilet/hand washing facilities.

Beneficiary records must be maintained at the permanent office with a copy in the mobile unit and must at minimum include date of service, history, chief complaint, tests/radiographs and results, diagnosis, treatment (including prescriptions), provider signature/initials, and copies of hospital/ER records when available.

All service limits and program-specific rules apply to services provided in mobile units.

DSMT coverage and limits

DSMT (Diabetes Self-Management Training) coverage, ordering, and limits:

DSMT is covered when medically necessary, ordered by the managing clinician (physician, PA, or NP actively managing the beneficiary's diabetes), prior authorized by the UM/QIO, Division, or designated entity, and provided under direct supervision by specified clinicians with programs meeting ADA/AADE accreditation standards.

DSMT providers must be current Mississippi Medicaid providers located in-state and accredited by the ADA or AADE; DOM does not enroll providers solely for DSMT.

Initial DSMT: one initial training per lifetime provided within a continuous six-month period beginning with the initial individual assessment, not to exceed seven hours total, delivered in increments of no less than 30 minutes; may include up to one hour individual assessment and up to six hours group training (group sessions consist of two or more individuals unless the ordering physician documents need for individual sessions).

Follow-up DSMT: must be ordered by the physician actively managing the beneficiary's diabetes with documentation of the specific condition addressed, furnished any time in the year following completion of the initial training, up to two hours per year, in increments no less than 30 minutes, and provided in group sessions of two or more unless documented otherwise by the ordering physician.

Beneficiaries under age 18 must be accompanied by a parent/guardian/legal representative for DSMT.

EPSDT-eligible beneficiaries receive medically necessary DSMT without regard to service limits with prior authorization per Part 223 of Title 23.

EHR and e-signature rules

EHR and e-signature rules — permitted uses and technical/legal requirements:

The Division recognizes EHRs as electronic versions of beneficiary medical history and clinical/administrative data; EHR content may include demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and imaging data.

E-signatures in EHRs are permitted provided they meet CEHRT/NIST/ONC criteria, comply with UETA and the ESIGN Act, maintain HIPAA compliance for access/transfer/storage/signing, and comply with Division e-signature requirements (refer to Part 200, Rule 1.10).

Beneficiaries may use an e-signature in an EHR only with consent, must be offered the option of electronic or handwritten signature, be furnished electronic or printed copies of electronically signed documents, and must comply with Division e-signature requirements.

Coverage criteria and reimbursement rules for AI/AN and DSMT

Coverage parity and reimbursement rules for American Indian/Alaskan Native (AI/AN) beneficiaries and DSMT follow-up:

AI/AN beneficiaries who meet Medicaid eligibility criteria receive the same benefits as other beneficiaries in the same eligibility category; all limitations, exclusions and prior authorization requirements apply.

AI/AN beneficiaries are exempt from Medicaid premiums and cost-sharing for items/services furnished by an Indian health care provider or through contract health services.

IHS/Tribal 638 facilities are reimbursed per applicable methodologies (e.g., inpatient per diem, outpatient encounter rate, dental encounter rate) and other approved providers are reimbursed per the current payment methodology; federal reimbursement (FMAP) rules apply (e.g., 100% FMAP where applicable).

DSMT follow-up training requirements: follow-up must be physician-ordered, documented in the medical record specifying the medical condition addressed, furnished in the year following completion of initial training, up to 2 hours per year in increments of no less than 30 minutes, and provided in group sessions of at least two participants unless the ordering physician documents a medical need for individual sessions.

EPSDT-eligible beneficiaries receive medically necessary services (including DSMT) without regard to service limits and with prior authorization.

Procedure, Billing, and Coding Rules

Regulatory citations referencedmixed

42 CFR 431.300-431.307	Confidentiality of beneficiary-specific information
HIPAA 45 CFR 160, 164	Privacy Rule applicability to public information access

NCCI and timed-code billing rulesmixedCovered

NCCI PTP and MUE edits

NCCI procedure-to-procedure edits and medically unlikely edits that control improper coding and maximum units per date of service

Timed-code rounding rulesmixedCovered

8 minutes	Minimum direct patient contact time to bill the first 15-minute unit
45 minutes	Minimum time to bill one-hour timed code (provider must have provided more than half of time allotment)

Non-covered service categoriesmixedNot Covered

Investigational/experimental	Services, procedures, supplies or drugs still in clinical trials deemed investigational or experimental
FDA-unapproved indications	Procedures/products/services for conditions/indications not approved by FDA or not supported by official compendia
Cosmetic procedures	Operative procedures performed primarily to improve physical appearance
Reconstructive breast procedures (symmetry)	Reconstructive breast procedures performed to produce a symmetrical appearance
Infertility treatments	Infertility studies, procedures to enhance fertility including reversal of sterilization, artificial/intrauterine insemination, in-vitro fertilization
Bariatric/obesity surgery	Gastric surgery techniques or procedures for treatment of obesity or weight control
Routine foot care (no systemic condition)	Routine foot care in the absence of systemic conditions
Prosthetics/orthotics (except Medicare crossover)	Prosthetic or orthotic devices and orthopedic shoes except crossover claims allowed by Medicare
Non-treatment items/services	Items or services not directly related to treatment of an illness or injury (e.g., television, massage, haircuts, interest on late pay claims, telephone consultations, missed/cancelled appointments, wigs)
Services by excluded/unlicensed providers	Services ordered/prescribed/administered/supplied/provided by excluded, de-licensed, non-enrolled or otherwise ineligible providers

1–10 of 12

1/2

Procedure code requests via enrollmentmixed

Provider enrollment requests

Requests to cover specific procedure codes should not be submitted through provider enrollment and will not be reviewed

340B dispensing identificationmixedCovered

NCPDP field values

Required identification fields for 340B purchased drugs as defined by Division of Medicaid for POS pharmacy claims

340B claim identifiersmixed

NCPDP field values; HCPCS; NDC

340B drugs must be identified with appropriate NCPDP field values for POS claims and with appropriate modifier plus HCPCS/NDC for physician-administered drugs (PAD)

IHS reimbursement rate typesmixed

No codes listed

Claim submission/processing timeframes

Claim timely filing windowProviders must submit claims no later than 365 calendar days from the date of service.

Newly enrolled providersClaims by newly enrolled providers must be submitted within 365 calendar days from date of service and must be for services on or after the provider's effective enrollment date.

Medicare-related claims processingIf a Medicare timely claim was filed, Medicaid will process the related Medicaid claim within 180 calendar days after notice of disposition of the Medicare claim.

Processing period definitionThe processing period begins on the date a claim is timely received and ends 365 calendar days from the date the original claim is received by the Division.

Effect of untimely filingIf a provider fails to meet timely filing requirements, the beneficiary cannot be billed for those services.

Minimum minutes to bill 15-minute unit

Minimum direct patient contact for first 15-minute unitProviders may bill the first 15-minute unit if direct patient contact time is at least eight (8) minutes.

Additional 15-minute incrementsAdditional 15-minute units may be billed after completing the initial full 15 minutes if at least eight (8) minutes of the next time block are used for direct patient services.

No rounding upProviders may not round up to the next timed code if less than eight (8) minutes of direct patient services are performed in a 15-minute increment.

Minimum minutes to bill one-hour unit

Minimum minutes to bill one-hour timed codeA provider must have provided services for more than half of the time allotment in the code description to bill the unit; for a one-hour unit the applicable rounding rule requires at least 45 minutes (more than half) of service to bill that hour.

Additional units billingAdditional units may be billed in increments provided that more than half of the time of each billable increment has been provided.

CPT/HCPCS precedenceProviders must adhere to CPT/HCPCS guidelines and NCCI policies; where conflicts exist, CPT/HCPCS guidelines take precedence.

Service limits for dual eligibles

Application of service limitsAll service limits apply to beneficiaries who are dually eligible for Medicare and Medicaid.

No additional payments after limits metOnce state service limits are reached each state fiscal year for a dually eligible beneficiary, no additional payments will be made for those services.

Provider payment acceptanceAll providers must accept the Medicare and Medicaid payment as payment in full; providers are prohibited from billing the beneficiary the balance between provider charges and Medicare/Medicaid payments.

Retroactive effective date window

Retroactive eligibility look-back periodRetroactive eligibility is available for up to a three (3) month period before application; applicants must meet financial and need requirements.

Retroactive effective date for enrollmentEffective date may be up to 120 days prior to application submission if DOM can verify required screenings were completed by a Medicare contractor or another state's Medicaid/CHIP agency.

Refunds and timely filingMedicaid-covered services paid for by a beneficiary during the retroactive period may be refunded and billed to Medicaid when eligibility is validated in accordance with timely filing requirements.

Medicare Tie-in Notice enrollment window

Medicare Tie-in Notice enrollment timingIf a provider requests enrollment within 120 days from the date the Medicare Tie-in Notice was issued, the provider's effective date may be the date of Medicare certification, not to exceed 365 days from the date of application.

Late enrollment effective dateIf the provider requests enrollment after 120 days from the Medicare Tie-in Notice issuance, the effective date is the first day of the month in which the Division receives the enrollment application.

Verification of prior screeningsAn effective date up to 120 days prior to application may be allowed if DOM can verify required screenings completed by Medicare contractor or another state's Medicaid/CHIP agency.

AAC reference date

AAC reference date for 340B POS claimsPoint-of-sale (POS) pharmacy providers must bill ingredient cost at the Actual Acquisition Cost (AAC) in effect as of July 1, 2021.

AAC definitionAAC is defined as the price the pharmacy paid the wholesaler or manufacturer for the 340B purchased drug with no mark-up plus the applicable professional dispensing fee.

Identification requirementProviders must identify 340B purchased drugs dispensed or administered with the appropriate NCPDP field values as defined by the Division of Medicaid.

POS ingredient cost basis

Ingredient cost basis for POS pharmacy claimsFor POS claims, bill ingredient cost at the Actual Acquisition Cost (AAC) in effect as of July 1, 2021 plus the applicable professional dispensing fee.

Identification of 340B drugsProviders must identify 340B purchased drugs with the appropriate NCPDP field values as defined by the Division of Medicaid.

Billing referencesPOS billing must follow Miss. Admin. Code Part 200, Rule 4.10.F and related Division instructions.

PAD billing cost basis

PAD billing cost basis SFY2021For medical claims, providers must bill 340B purchased Physician Administered Drugs (PAD) at the same cost in effect for State Fiscal Year (SFY) 2021 with the appropriate modifier and corresponding HCPCS and NDC.

Modifier and code requirementsUse the appropriate modifier to identify the 340B purchased drug and include the corresponding HCPCS and NDC on medical claims.

Contract pharmacy prohibitionA contract pharmacy acting as an agent of a 340B covered entity cannot dispense and bill Medicaid for 340B outpatient drugs.

DSMT annual follow-up hours

Annual DSMT follow-up hour limitFollow-up DSMT includes a maximum of two (2) hours each year.

Ordering and documentationFollow-up training must be ordered by the physician actively managing the beneficiary's diabetes with documentation in the medical record of the specific medical condition addressed.

Session increments and group sizeFollow-up DSMT is furnished in increments of no less than 30 minutes and is provided in group sessions of two or more unless the ordering physician documents need for individual sessions.

Federal reimbursement percentage for IHS-provided services

Federal reimbursement percentageOne hundred percent (100%) Federal Medical Assistance Percentage (FMAP) is available for amounts spent on medical assistance received through an Indian Health Service facility or Tribal 638 facility.

IHS/Tribal reimbursement methodsIHS/Tribal 638 facilities are reimbursed as inpatient per diem, outpatient encounter rate, dental encounter rate; other approved providers reimbursed per current payment methodology.

Statutory basis100% FMAP availability is in accordance with the Social Security Act and Indian Health Care Improvement Act provisions.

Provider Responsibilities, Notifications, and Operational Rules

Documentation Required

Limit disclosure of Medicaid records; beneficiary release and confidentiality agreement required

Providers may disclose Medicaid-acquired records only when the record or information is to be used in connection with a claim, to verify utilization of Medicaid benefits, or when disclosure is necessary for the proper performance of duties of specified entities (Division of Medicaid, contracted agencies, MFCU, duly authorized legal hearing, or representative of the Secretary of HHS). Release of information to collection/billing agencies requires a signed release from the beneficiary, and business agents/billing services may receive information only if they have a written agreement with the provider and a confidentiality agreement on file with the fiscal agent. State law requires any released medical information to identify the person as a Medicaid beneficiary, include the Medicaid ID number, and state whether the bill has been paid or will be submitted to Medicaid.

Disclosure permitted only for claims, utilization verification, or authorized duties of named entities.
Collection/billing agencies may receive information only with beneficiary signed release or if the agency has a written agreement with the provider and a confidentiality agreement on file with the fiscal agent.
Released records must state beneficiary status, Medicaid identification number, and payment/submission status.

Prior Authorization

Adhere to 365-day timely filing; Medicare-tied processing and beneficiary billing prohibition

Submit claims no later than 365 calendar days from the date of service; newly enrolled providers must also submit claims within 365 days and only for services on or after their enrollment effective date. If a Medicare claim was timely filed, DOM will process the related Medicaid claim within 180 calendar days after notice of Medicare disposition. If timely filing requirements are not met, the beneficiary cannot be billed for those services.

Standard timely filing limit: 365 days from date of service.
Newly enrolled providers: claims still subject to 365-day limit and must be for dates on/after provider effective date.
Medicare-tied processing: DOM will process related Medicaid claims within 180 days after Medicare disposition.
Failure to meet timely filing: beneficiary may not be billed.

Documentation Required

Submit corrected claims, pursue Administrative Review within 90 days, and maintain Appointment of Authorized Representative

Providers may submit corrected claims during the processing period. If DOM adjusts claims after the processing period, providers may request an Administrative Review in writing within 90 calendar days of the remittance advice and must submit supporting documentation. To delegate claim submission authority, providers must complete and keep on file the Appointment of Authorized Provider Representative or Agent form and ensure the representative meets character requirements.

Corrected claims may be submitted during the processing period.
Administrative Review request must be filed within 90 days of the remittance advice when claims are adjusted after processing period; include documentation.
Authorized representative: use the Appointment form, retain it at main office, and ensure representative has no disqualifying convictions.

Prior Authorization

Submit EVV-linked claims through state EVV system unless DOM authorizes otherwise

Claims for services that require Electronic Visit Verification (EVV) must be submitted to the fiscal agent via the state's approved EVV system unless the Division of Medicaid has provided written authorization otherwise.

Ensure EVV visit data are captured in the approved EVV solution or entered into it if manually captured.
Maintain audit trail and grant system access to DOM and contractors for auditing.
Only submit EVV-linked claims through the state's EVV system unless DOM authorizes an alternative in writing.

Prior Authorization

Do not deny retroactive-eligibility services for lack of prior authorization; obtain authorization and file within 90 days

For services rendered during retroactive eligibility, medically necessary services that require authorization cannot be denied for failure to secure prior authorization; however, authorization must be obtained and the claim filed within ninety (90) days of the system add date of the eligibility determination.

Retroactive eligibility covers services during a three-month period before application when financial/need criteria are met.
Obtain authorization and file claims within 90 days of the system add date for retroactive eligibility.

Prior Authorization

Follow managed-care freedom-of-choice exception: PCP authorization required for specialty care

When a federal waiver or approved State Plan amendment restricts freedom of choice (e.g., managed care), beneficiaries must receive primary care from a PCP and specialty care must be prior authorized by that PCP.

In managed care waiver or SPA scenarios, freedom of choice may be restricted as described.
Specialty care requires prior authorization by the beneficiary's PCP under these exceptions.

Billing Rule

Accept Medicaid payment as payment in full; do not split services to shift costs to beneficiary

Providers must agree to accept Medicaid payment as payment in full for Medicaid-covered services within beneficiary service limits and may not split services to require beneficiary payment where Medicaid covers the service.

Accept Medicaid reimbursement as payment in full except authorized deductibles, co-insurance, and copayments.
Do not require beneficiaries to pay deposits or split a service between beneficiary payment and Medicaid.

Prior Authorization

Out-of-state providers may enroll only under specified conditions with supporting documentation

The Division may enroll out-of-state providers only when specified conditions are met (emergency, travel would endanger beneficiary, services more readily available out-of-state, within specified mileage of the border, or as determined by DOM). Providers must submit supporting documentation and adhere to DOM policies and screening results may be accepted from other states or Medicare contractors.

Eligible reasons include emergency conditions, health risks if beneficiary must travel, or lack of in-state provider availability.
Service location limits: pharmacies within 30 miles of border; certain other providers within 60 miles; or as DOM determines.
Submit documentation supporting the need for out-of-state enrollment; DOM may rely on other-state or Medicare screenings.

Prior Authorization

Payment may continue up to 30 days after termination for beneficiaries admitted before termination

Providers of inpatient hospital, nursing facility, PRTF, ICF/ID/DD, home health, and hospice services will continue to receive payment for up to thirty (30) days after provider agreement termination for services furnished to beneficiaries admitted before termination to permit orderly transfer; providers must follow required notification and transition procedures.

Payment continuation limited to 30 days post-termination for listed service types for beneficiaries admitted prior to termination.
Facilities must notify beneficiaries/families within 48 hours, submit current beneficiary lists, and assist with transfers.

Billing Rule

Bill 340B POS claims using AAC (7/1/2021) plus dispensing fee and identify 340B drugs with NCPDP fields

340B covered entities that opt in must bill point-of-sale pharmacy claims using the actual acquisition cost (AAC) in effect as of July 1, 2021 for ingredient cost plus the applicable dispensing fee, and must identify 340B-purchased drugs using the appropriate NCPDP field values defined by the Division.

POS ingredient cost basis: AAC as of July 1, 2021, plus dispensing fee.
Identify 340B purchased drugs with the NCPDP field values required by DOM.

Documentation Required

Notify DOM of 340B opt-in/opt-out and submit 340B Attestation & Enrollment; recertify and provide invoices

Providers participating in the 340B program must notify the Division of Medicaid of their opt-in/opt-out election by submitting the Division's 340B Covered Entity Attestation & Provider Enrollment Form, register and recertify with HRSA, recertify annually, notify DOM in writing of any change in election, dispense/administer 340B drugs only to eligible beneficiaries, and submit drug invoices as required for audit.

Register with HRSA and obtain HRSA identification number, and recertify with HRSA annually.
Submit the Division's 340B Covered Entity Attestation & Provider Enrollment Form indicating opt-in or opt-out and notify DOM immediately of any change.
Dispense/administer 340B drugs only to eligible beneficiaries and provide invoices for audit as required.

Prior Authorization

Obtain prior authorization and clinician order for DSMT; meet ADA standards

DSMT must be ordered by the physician, physician assistant, or nurse practitioner actively managing the beneficiary's diabetes and prior authorized by the UM/QIO, the Division of Medicaid, or a designated entity; the program must meet current ADA standards and be provided under specified clinician supervision.

Order must come from the clinician actively managing the beneficiary's diabetes.
Prior authorization required from UM/QIO, DOM, or designated entity before providing DSMT.
Program must meet current ADA training standards and be provided under direct supervision of specified licensed clinicians.

Documentation Required

Physician-ordered and documented DSMT follow-up: 2 hours/year, ≥30-minute increments, group preferred

Follow-up DSMT must be ordered by the physician actively managing the beneficiary's diabetes and documented in the medical record with the specific medical condition the training will address; follow-up is furnished in the year after initial training, limited to two hours per year in increments of no less than 30 minutes and generally provided in group sessions of two or more unless physician documents need for individual sessions.

Physician order must include documentation of the specific medical condition the follow-up training addresses.
Follow-up DSMT: maximum 2 hours per year, increments ≥30 minutes, furnished any time in the year following the year of completion of initial training.
Group sessions of two or more are standard unless ordering physician documents need for individual sessions.

Prior Authorization

EPSDT beneficiaries: medically necessary services paid without regard to limits, with prior authorization

For EPSDT-eligible beneficiaries, the Division pays for all medically necessary services without regard to service limitations; such services still require prior authorization per the applicable rules.

EPSDT beneficiaries receive medically necessary services regardless of stated service limits.
Prior authorization is required even when EPSDT overrides service limitations (refer to Part 223 of Title 23).

Key Terms and Definitions

Medical records

Medical records definitionMedical records are documentation supporting medical services which fully disclose the extent of services, care and supplies furnished to a beneficiary and support claims billed; records must be legible, appropriate, and correct.

Access and productionProviders must make records available to representatives of DHHS, CMS, the Division of Medicaid, or the Mississippi Medicaid Fraud Control Unit upon request.

Record integrityEntries must be permanent, legible, and corrections must be documented by drawing a single line through errors with date/time and initials; tampering or falsifying records is illegal.

Confidential information

Confidentiality of Social Security Act recordsRecords and information acquired in administration of any part of the Social Security Act are confidential and may be disclosed only under DHHS rules or when authorized by the Secretary of HHS.

Permitted disclosuresA provider may disclose records for claims, utilization verification, or when necessary for duties of specified entities (Division, contracted agencies, MFCU, legal hearings, HHS representatives).

Third-party/billing agency restrictionsDivision and fiscal agent cannot release information to collection/billing agencies without a signed release from the beneficiary; disclosure to a provider's billing agent requires a written agreement and confidentiality agreement on file with the fiscal agent.

Clean claim

Clean claim definitionA clean claim is one that can be processed without obtaining additional information from the provider or a third party; claims with errors originating in the Division's system are considered clean.

Not clean claims examplesClaims from providers under investigation for fraud or abuse and claims under medical necessity review are not considered clean claims.

Processing timelinesThe Division processes all claims within 365 calendar days from date of receipt except as specified (e.g., Medicare-related timing, retroactive adjustments, investigations, court/hearing orders).

Authorized provider representative

Authorized provider representative definitionAn authorized provider representative is an employee or agent designated by the provider, with the provider's knowledge and written consent, to manage and submit claims to the Division of Medicaid for payment.

Character requirementsAn authorized representative must not have certain felony or specified misdemeanor convictions related to dishonesty or concealment; pardons or reversals do not mitigate this requirement.

Form and recordkeepingProviders must use the Appointment of Authorized Provider Representative or Agent Form from the Provider Billing Handbook and keep it on file at the provider's main office, available to DOM upon request.

Electronic signature

Electronic signature definitionAn electronic signature is an electronic symbol attached to or logically associated with a document or communication and is recognized when executed by a person with intent to sign.

Equivalence to handwritten signatureThe Division considers electronic signatures the equivalent of full handwritten signatures or initials and will not deny solely because a signature is electronic.

EHR e-signature requirementsE-signatures in EHRs must meet CEHRT/NIST/ONC criteria, comply with UETA and ESIGN Act standards, maintain HIPAA compliance, and follow Division e-signature requirements.

Freedom of Choice of Providers

Freedom of choice rightMedicaid beneficiaries have the right to freedom of choice of providers for Medicaid covered services and may obtain assistance from any qualified provider.

Provider restrictionsProviders may not restrict beneficiaries' freedom of choice, require waivers that deny choice, or use inducements (transportation, gifts, cash) to influence beneficiary selection.

Managed care exceptionUnder federal waiver or approved SPA, freedom of choice may be restricted for enrollees in managed care programs who must receive primary care from a PCP and have specialty care prior authorized by the PCP.

Retroactive Eligibility

Retroactive eligibility definitionRetroactive eligibility is available during all or part of a three (3) month period before application for Medicaid if applicants meet financial and need requirements.

Provider refund optionMedicaid-covered services paid for by a beneficiary during the retroactive period may be refunded at the option of the provider and billed to Medicaid when eligibility is validated and timely filing requirements met.

Authorization during retroactive periodMedically necessary services requiring authorization during the retroactive period cannot be denied for failure to secure prior authorization; authorization must be obtained and claim filed within 90 days of the system add date of eligibility determination.

Medicare/Medicaid dual eligibility rules

Medicare primary payerMedicare is the primary payor for beneficiaries eligible for both Medicare and Medicaid.

Medicaid payment of Medicare premiumsThe Division pays Medicare Part A and Part B premiums through 'buy-in' processes for eligible low-income beneficiaries and specified low-income Medicare beneficiaries (SLMB, QI) as described.

Pharmacy crossover treatmentFor beneficiaries with both Medicare and Medicaid, pharmacy providers must bill Medicare for drugs covered by that program and the Division considers the Medicare payment as payment in full for Medicare Part D pharmacy claims.

Provider

Provider definitionProviders include all health care entities and individual practitioners, institutional providers, and suppliers of medical equipment or goods currently enrolled in the Medicaid program.

Enrollment requirementProviders must be enrolled in the Medicaid program to be considered a provider for purposes of these rules.

Types includedExamples include hospitals, long-term care facilities, laboratories, home health agencies, ambulance companies, group practices, and pharmacies.

National Provider Identifier (NPI)

NPI definitionNational Provider Identifier (NPI) is a HIPAA Administrative Simplification Standard: a unique identification number for covered health care providers as noted in 45 C.F.R. § 162 used in administrative and financial transactions.

UsageCovered health care providers and all health plans and healthcare clearinghouses must use NPIs in HIPAA-adopted administrative and financial transactions.

Enrollment associationNPIs are entered into the Medicaid system with provider billing numbers and tax identifiers as applicable.

Sole Proprietor

Sole proprietor definitionA sole proprietor is a business form where one person owns all assets and is solely liable for debts; must apply for an individual NPI and Medicaid will no longer issue a group number to an individual.

Billing and tax reportingAn individual Medicaid provider number and the appropriate NPI are entered into the Medicaid system with the individual's SSN and, if applicable, FEIN; income reported to IRS accordingly.

Subpart concept inapplicableThe subpart concept does not apply to a sole proprietorship even with multiple locations because it is not an organization under the NPI rule.

Group/Organization provider

Group/Organization provider definitionA Group/Organization provider is a non-individual provider (e.g., hospitals, long-term care facilities, labs, agencies, suppliers) and subparts must apply for different Medicaid provider numbers as determined by provider type.

Billing and IRS reportingFor monies to be reported to the IRS on its Tax Identification, the group provider should be the biller unless restricted by the Division of Medicaid.

Multiple servicing locationsGroup providers with various servicing locations should apply to Medicaid to become a provider according to enumeration application with CMS and Division rules.

Managing/Directing Employee

Managing/Directing Employee definitionA managing/directing employee is an individual who exercises operational or managerial control over day-to-day operations, whether a W-2 employee or under contract.

ExamplesMay include general manager, business manager, administrator, director, or other individuals exercising control over operations.

Role in delegationDelegated officials reporting changes must be an ownership/control interest or a W-2 managing employee and require documentation signed by an authorized official.

Authorized Official

Authorized Official definitionAn Authorized Official is a person granted legal authority to enroll the organization in Medicaid, make updates, and commit the organization to Medicaid statutes and regulations (e.g., CEO, CFO).

Authority scopeExamples include chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner.

Delegation implicationsAn Authorized Official may delegate responsibilities to a Delegated Official with appropriate documentation for enrollment changes.

340B provider

340B provider definitionA 340B provider is a nonprofit healthcare organization that meets requirements of, and is considered a covered entity under, Section 340B of the Public Health Service Act and has elected to enroll in the 340B program.

340B purchased drugsDefined as drugs produced by manufacturers complying with Section 1927(a), purchased and administered/dispensed by 340B covered entities under 340B rules, and dispensed to 340B eligible beneficiaries.

Eligibility of beneficiariesA 340B eligible beneficiary has an established relationship with the covered entity, received care from employees or contractors of the covered entity, and received services consistent with the entity's grant funding or FQHC look-alike status (with DSH exceptions).

340B opt-in / opt-out

340B opt-in / opt-out electionCovered entities participating in 340B must notify the Division of Medicaid of their election to opt-in or opt-out of billing the Division for 340B purchased drugs by submitting the 340B Covered Entity Attestation & Provider Enrollment Form.

Opt-in obligationsOpt-in entities must register with HRSA, receive an HRSA ID, recertify annually, dispense/administer 340B drugs only to eligible beneficiaries, bill per Division rules, and submit drug invoices for audit.

Opt-out obligationsOpt-out entities must complete and submit the attestation form indicating election to opt-out and must notify the Division immediately of any change in election.

opt-in

Opt-in definitionOpt-in means electing to dispense and/or administer drugs purchased under the 340B program and billing the Division of Medicaid for eligible Medicaid beneficiaries.

Required registrationOpt-in covered entities must register, enroll and receive an identification number from HRSA and submit the Division's 340B Attestation & Enrollment Form.

Annual recertification and notificationOpt-in entities must recertify with HRSA annually and notify the Division in writing of any changes in 340B election status.

opt-out

Opt-out definitionOpt-out means a covered entity elects never to bill the Division of Medicaid for 340B purchased drugs.

Form requirementOpt-out election must be indicated by completing, signing and submitting the 340B Covered Entity Attestation & Provider Enrollment Form to the Division of Medicaid.

Immediate notification of changesCovered entities must notify the Division immediately of any change in their election to opt-in or opt-out.

medically necessary

Medically necessary definition'Medically necessary' services are those a provider, exercising prudent clinical judgment, would provide to evaluate, diagnose or treat illness/injury and that are appropriate, consistent with diagnosis, compatible with US standards of practice, safe, not custodial, not solely for convenience, not experimental, and no less costly effective alternative exists.

Coverage caveatMedical necessity alone does not guarantee reimbursement; program policies, exclusions, limitations and service limits still apply.

ApplicationMedically necessary criteria are applied when determining coverage under Division policies.

mobile medical unit

Mobile medical unit definitionA mobile medical unit is a self-contained facility or unit that can be moved, towed, or transported and provides prevention, screening, diagnostic, and treatment services (excludes IDTFs).

Exclusion noteThis rule and definition exclude services provided in an Independent Diagnostic Treatment Facility (IDTF).

Operational implicationMobile units must meet Part 200 Chapter 4 enrollment and operational requirements when providing Medicaid services.

DSMT

DSMT definitionDiabetes Self-Management Training (DSMT) is an interactive and collaborative process through which beneficiaries with diabetes gain knowledge and skills to modify behavior and self-manage the disease and related conditions.

Provider enrollment for DSMTThe Division does not enroll providers solely for DSMT; DSMT providers must be current Mississippi Medicaid providers located in-state and accredited by ADA or AADE.

Relation to reimbursementProviders seeking reimbursement for DSMT must meet Rule 4.8 provider criteria in addition to DSMT accreditation requirements.

EHR

EHR definitionElectronic Health Record (EHR) is an electronic version of a beneficiary's medical history and key administrative clinical data maintained by a provider over time and may include demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and imaging data.

EHR e-signature useProviders may use e-signatures in EHRs but e-signatures must meet CEHRT/NIST/ONC criteria, comply with UETA and ESIGN Act, and maintain HIPAA compliance; Division e-signature requirements apply.

Beneficiary e-signature rightsBeneficiaries must consent to use of an e-signature, be given option of electronic or handwritten signature, and be furnished electronic or printed copies of electronically signed documents.

IHS/Tribal 638 Facilities

IHS/Tribal 638 participationIndian Health Service (IHS) Facilities and Tribal 638 Health Facilities are accepted as Medicaid providers on the same basis as other qualified providers; they must meet applicable state licensure standards but need not obtain a state license.

Reimbursement methodsIHS/Tribal 638 facilities are reimbursed as inpatient per diem, outpatient encounter rate, dental encounter rate; other approved providers reimbursed per current payment methodology.

100% FMAP availabilityOne hundred percent (100%) FMAP is available to states for amounts spent on medical assistance received through an IHS facility whether operated by IHS or an Indian tribe/organization.