15 Miss. Code. R. 16-1-82.7.3

Current through December 10, 2024

Rule 15-16-1-82.7.3

Except as otherwise provided in these standards, a private review agent should limit its initial data requirements to the following elements:

1. Patient Information

a. Name

b. Address

c. Date of Birth

d. Sex

e. Social Security Number or Patient ID Number

f. Name of Carrier or Plan

g. Plan ID Number

2. Enrollee Information

a. Name

b. Address

c. Social Security Number or Employee ID Number

d. Relation to Patient

e. Employer

f. Health Benefit Plan

g. Group Number/Plan ID Number

h. Other Coverage Available (Workers Comp., Medicare, etc.)

3. Attending Physician/Practitioner Information

a. Name

b. Address

c. Phone Number

d. Degree

e. Specialty/Certification Status

f. Tax ID or Other ID Number

4. Diagnosis/Treatment Information

a. Primary Diagnosis

b. Secondary Diagnosis

c. Proposed Procedure(s) or Treatment(s)

d. Surgical Assistant Requirement

e. Anesthesia Requirement f. Proposed Admission or Service Date(s)

g. Proposed Procedure Date

h. Proposed Length of Stay

5. Clinical Information. Sufficient information for support of appropriateness and level of service proposed

6. Facility Information

a. Type (such as in-patient, out-patient, rehab, etc.)

b. Status (DRG exempt status, as needed)

c. Name

d. Address

e. Phone Number

f. Tax ID or Other ID Number

7. Concurrent (Continued Stay) Review Information

a. Clinical Contact Person

b. Additional Days/Services Proposed

c. Reasons for Extension

d. Diagnosis (same/changed)

e. Clinical Information (Sufficient to support, as above)

8. Admissions to Facilities Other Than Acute Medical/Surgical Hospitals

a. History of Present Illness

b. Patient Treatment Plan and Goals

c. Prognosis

d. Staff Qualifications

e. 24 Hour Availability of Staff

15 Miss. Code. R. 16-1-82.7.3

Miss. Code Ann. §41.83.1