If a service is provided to a claimant out of state, whose
rule for reimbursement of records applies? (i.e. If seen in Alabama do we have to pay copy
costs for Alabama or do the Mississippi rules apply?)
Our rules and regulations always apply if this is a Mississippi jurisdiction.
What is the jurisdiction of the Mississippi Workers Compensation
The Fee Schedule is applicable for services provided within the state of
Mississippi. It applies to injured workers, whether Mississippi claims
or not. If a Mississippi claimant is treated in a neighboring state,
then the Fee Schedule of that state is applicable.
If a procedure is not listed in the Fee Schedule, what is the
A procedure code that is not listed in the Fee Schedule should be
reimbursed at the usual and customary rate.
Are medical records required for reimbursement of medical charges?
Yes, employers/payers need medical records for review of diagnosis and
applicability to the workers compensation claim.
Is there a dental fee schedule?
No, there is no dental fee schedule in Mississippi. The reimbursement
for dental services should be at the usual and customary rate.
Can the reimbursement for medical services be reduced lower than the
Fee Schedule amount?
Yes, if an employer/payer has a contractual agreement with a provider
designed to reduce the cost of workers compensation health services, the
contractual agreement shall be exempt from the fee schedule.
Can medical payments be made on controverted/litigated claims?
Yes, reimbursement for medical charges may be made on controverted
claims. However, the employer/payer may suspend payments of indemnity
and/or medical pending a decision by an administrative judge.
What is the penalty for untimely filing of medical charges or
untimely payment of medical charges?
It is ten percent (10%) per 30-day period.
HCFA-1500 form and documentation must be filed within 20 days for a
newly diagnosed work-related injury or injury; and within 30 days for
subsequent billings. Otherwise, the bill may be reduced by 10% for each
30-day period for late billing.
Likewise, payment of properly submitted, documented, bills should be
made with 30 days of receipt. If no payment is made within 60 days, then
a payer may be subject to penalties not to exceed 10% for each 30-day
period after 60 days.
Is the employee or employer responsible for the balance of a paid
No, if the payment has been made properly according to the medical fee
schedule, then fees in excess of the maximum reimbursement allowable
rate must not be billed to the employee or employer.
If authorization is given for medical treatment, can payment be
denied when bill received?
No. When authorization is given, services are provided in good faith,
therefore, payment must be rendered. Reimbursement determinations shall
be based on medical necessity of services to either establish a
diagnosis or treat an injury/illness. Thus reimbursement shall not be
dependent on the outcome of medically necessary diagnostic services or
Are Explanation of Benefits forms required with every payment of
No, but the Explanation of Benefits form is required whenever the
reimbursement amount is less than the charged amount, and it must be
provided with the reimbursement check.
If the carrier disputes a bill, is payment required? What action is
The carrier is required to pay the undisputed portion of the bill within
30 days of receipt. And for the disputed portion, the carrier shall
notify the provider within 30 day of the receipt of the bill of the
reasons for disputing the bill or portion thereof, and shall notify the
provider of its right to provide additional information and to request
reconsideration of the carrier's action. The carrier must specify the
reasons of dispute.
How can the medical provider request reconsideration of
The provider must make a written request within 30 days from receipt of
the Explanation of Benefits form. Allowances may be made by payer for
the period of time in submission of reconsideration requests. The payer
must respond within 30 days of receipt to the request for
reconsideration. The payer must review and re-evaluate the original bill
and respond accordingly. If the medical provider is still dissatisfied,
then a request for dispute resolution should be filed with the MWCC
Medical Cost Containment Department.
May a Mississippi injured worker receive medical treatment out of
Yes, however, prior authorization must be obtained from the payer for
referral to out-of-state providers. Reimbursement for out-of-state
services shall be based on one of the following: the workers'
compensation fee schedule for the state in which services are rendered
or the usual and customary fee for the geographical area in which the
services are rendered.
When can the payer receive the report of Maximum Medical Improvement?
The physician should submit a report with the date of MMI to the payer
or self-insured employer within 14 days of the date of MMI date even
though the employee may require further medical care. MMI is reached
when the maximal benefit from medical treatment is as far restored as
the permanent character of his injuries will permit and/or the current
limits of medical science will permit.
What is the reimbursement rate for Medical Depositions and
Reimbursement for a deposition is limited to $350 for the first hour and
$85 per quarter hour thereafter.
The Physician's Medical Record Custodian is allowed to sign the
affidavit in lieu of physician's signature. Such charge for execution of
the affidavit is limited to a maximum reimbursement of $25.
Reimbursement for copies of medical records is outlined in the fee
schedule and applies to copies of medical records which are attached to
What is the reimbursement rate for Medical Records?
There is no charge to the payer for the initial medical reports attached
to medical charge form.
Additional medical reports will be reimbursed as follows:
1-5 pages - $15.00
6+ pages - $ 0.50 per page in addition to the first 5 pages.
Hospitals and other inpatient facilities must submit required
documentation with the UB-92.
a) Admission, history, and physical
b) Discharge summary
c) Operative reports
d) Pathology reports
e) Consultations and other dictated reports
f) Emergency Room Records
Any additional reports or records requested by the payer will be
reimbursed as follows:
1-5 pages - $15.00/per admission
6+ pages - $ 0.50/per page/per admission in addition to the first 5
There is a maximum allowed fee of $50 for a particular inpatient medical
record. This is per admission.
What medical treatment may be denied?
Treatment of conditions unrelated to the injuries sustained in an
industrial accident may be denied as unauthorized if the treatment is
directed toward the non-industrial condition or if the treatment is not
deemed necessary for the patient's rehabilitation from the industrial
Are experimental or investigational procedures covered by the fee
No, the service must be widely accepted by the practicing peer group,
based on scientific criteria, and determined to be reasonably safe. It
must not be of an experimental, investigational, or research in nature
except in those instance in which prior approval of the payer has been
What are medically necessary services?
Medically necessary services are either those required for the remedial
treatment or diagnosis of an on-the-job injury, a work-related illness,
a pre-existing condition affected by the injury or illness, or a
complication resulting from the injury or illness and for such period as
the nature of the injury or process of recovery may require.
Is there a separate charge for a report of release from a physician?
No, a plan of care should be included in the medical record and should
address, as applicable, the following:
a) Degree of restoration anticipated
b) Measurable goals
c) Specific therapies to be used
d) Frequency and duration of treatments to be provided
e) Anticipated return to work date
f) Projected impairment
What is the pharmacy reimbursement rate?
Average Wholesale Price for the purpose of this fee schedule means AWP
base on the updated Drug Topics Red Book.
Brand name Medications - AWP plus $5.00 dispensing fee
Generic Medications - AWP plus 10% plus $5.00 dispensing fee
Over-the counter medications - usual and customary rates.
What is the authorization response time from payers?
Two days, the payer must respond within two (2) days to a request of
prior authorization for non-emergency services.
Which medical treatments require prior authorization by payer?
1) Non-emergency elective inpatient hospitalization
2) Non-emergency elective inpatient surgery
3) Non-emergency elective outpatient surgery
4) Physical medicine treatments after 15 visits or 30 days, whichever
5) Rental or purchase of supplies or equipment over the amount of $50
6) Rental or purchase of TENs
7) Home health services
8) Pain clinic/therapy programs
9) External Spinal stimulators
10) Pain control programs
11) Work hardening programs, back schools, functional capacity testing,
ISO kinetic testing
12) Referral for orthotics or prosthetics
13) Referral for acupuncture
14) Referral for biofeedback
15) Referral to psychological testing/counseling
16) Referral to substance abuse program
17) Referral to weight reduction program
18) Referral to any non-emergency medical service outside the state of
Which medical treatments require prior certification or mandatory
1) All admissions to inpatient facilities of any type
2) All surgical procedures, inpatient and outpatient
3) Repeat MRI (Magnetic Resonance Imaging) more than 1 per injury
4) Repeat CAT (Computerized Axial Tomography) more than 1 per injury
5) Work Hardening Programs, Pain Management Programs, Back Schools,
Massage Therapy, Acupuncture, Biofeedback
6) External Spinal Stimulators
7) FCE and Isokinetic testing
8) Physical Medicine treatments
9) Home Health
What is the appeal process for denial of medical necessity by
First level clinical review of admissions, procedures, and services may
be conducted by registered nurses and other appropriate licensed or
certified health professionals.
Second level clinical review is conducted by appropriate clinical peers.
Third level clinical review is conducted by appropriate clinic peers who
were not involved in second level review.
Commission Peer Review may then be requested through the Commission of
an objective physician in that specialty field.
What is the reimbursement rates for hospitals?
Inpatient rates are based on a daily per diem depending on the type of
stay, surgical, medical, etc. When specific criteria are met, an
additional Stop Loss amount may be paid, which is 80% of the additional
Outpatient rates are listed in 9 groupings in the Ambulatory Surgery
Centers Appendix. This is in addition to appropriate separately
When is next Fee Schedule update?
This year 2002 approximately August, effective date November 1, 2002,
the Updated Mississippi Workers Compensation Medical Fee Schedule will
be available. Preliminary copy available at the Commission for viewing.
Where can the 2002 Fee Schedule be obtained?
here to go directly to the Medicode website.
Mississippi Workers' Compensation Fee Schedule
c/o Ingenix/Medicode, Inc.
P O Box 27116
Salt Lake City, UT 84127-0116
Who do I contact at the Commission for questions related to the Fee
Mississippi Workers' Compensation Commission
Medical Cost Containment Department
P O Box 5300
Jackson, MS 39296-5300
shofmister at mwcc.state.ms.us (replace the 'at' with @ and remove the
When an outpatient visit is billed and it is not an ASC
bill and not an ER bill, if there are charges for EKG, can they be paid at fee schedule
When the patient goes to the hospital as outpatient for a
myelogram and they charge a fee for revenue code 360 or 361 and bill for the injection for
the myelogram, that should be denied and the other charges paid as separate outpatient
x-ray and lab. Is this correct?
Yes, deny 360 or 361. Pay S & I to hospital, and pay lab as separate outpatient.
The technical portion of the procedure pays for use of the facility. Also, pay for
I need to know if we should be paying a 23-hour surgery
differently from an outpatient surgery. I have been paying them as the same but have been
asked about why I do not pay observation charges in addition to the surgery. Which is
It is an outpatient surgery as long as it is under 24 hours. The definitions of
observation are listed in the fee schedule. It states that we do not pay observation
on standing orders. If you are referring to the calls from Methodist Rehab Center, this is
nothing but outpatient surgery with standing orders for observation following outpatient
surgery. I have told them to forward the disputes to me and I would be glad to look at
them. They have just realized they are only getting $600 and $700 for outpatient
surgeries. Outpatient is for a period not to exceed 23 hours.