Mississippi MS

Mississippi Division of Medicaid (DOM) publishes PA centrally as DOM authority, in two state-owned tracks: (1) FFS NON-PHARMACY PA = a single master XLSX 'DOM-MESA Procedure Code Prior Authorization Required' listing every CPT/HCPCS that needs PA; FFS UM adjudicated by Telligen (msmedicaid.telligen.com / Qualitrac) via the MESA provider portal (Gainwell, replacing legacy Envision). (2) PHARMACY PA = state-administered: a 'Drugs Requiring PA' master XLSX + dozens of DOM-published per-drug / per-class PA criteria PDFs (e.g. Hep C, opioid, growth hormone, anti-obesity, EPSDT, PDL exception), plus a General PA Instructions PDF and a Universal PA Request form. Managed-care MEDICAL PA is delegated to the MississippiCAN MCOs, which now number FOUR: Magnolia (Centene), Molina, UnitedHealthcare, and TrueCare (new — state_meta still lists only 3). So MS is NOT a single-portal state and NOT MCO-delegated for FFS criteria: DOM itself publishes the FFS code grid + all pharmacy criteria; only managed-care medical PA is per-MCO. Authority = DOM (Telligen FFS UM vendor, Gainwell/MESA fiscal agent/portal). Admin Code Title 23 carries underlying policy.

Last award: 2024-08-12. Next due: 2028-04-01 (estimated; based on standard ~12-month reprocurement lead before 2028-08-11 contract expiration). Contracts extended through: 2028-08-11.

status=partial

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How MS requires prior authorization Mississippi's Medicaid program (Division of Medicaid, DOM) requires prior authorization (PA) for a wide range of medical services, drugs, and devices, via a dual-track system: - **FFS Non-Pharmacy PA**: DOM publishes a master spreadsheet ("DOM-MESA Procedure Code Prior Authorization Required") listing all CPT/HCPCS codes that require PA, maintained via the MESA system / fiscal agent. - **FFS Pharmacy PA**: A combination of state-published criteria documents and the Universal Preferred Drug List (PDL). Preferred drugs generally do not require PA; non-preferred drugs may require PA per clinical criteria. - **Managed Care Delegation**: Under MississippiCAN, MCOs run their own PA processes within DOM's framework; pharmacy is carved in (processed through state channels). ## 2. How MS publishes and reports prior authorization - **Centralized Spreadsheet**: The DOM-MESA procedure-code PA list (FFS non-pharmacy) is available via the MESA provider portal and updated regularly. - **State Pharmacy Criteria PDFs**: Per-drug/per-class criteria packets (e.g., anti-obesity agents, biologics, specialty drugs), also via the MESA portal. - **Provider Portal (MESA)**: Central hub for accessing PA requirements, submitting requests, and tracking status. - **Billing Manuals**: General claims guidance (e.g., paper-claims billing manual) at medicaid.ms.gov/providers. ## 3. MS's CMS-0057-F and prior-authorization-reform compliance posture - **WISeR: Not applicable.** Mississippi is **not** a WISeR (CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model) state. The six WISeR states are AZ, NJ, OH, OK, TX, WA. The synthesis's invented expansion ("Workforce Innovation in States") has been removed. - **Gold Card Law**: Mississippi enacted gold-card legislation (per source documents; a specific bill number "SB 2140 / 2024 session" appears in the synthesis but is unverified — confirm against statute) aimed at streamlining PA for certain drugs/services. - **CMS-0057-F**: A federal interoperability/PA **rule** Mississippi must align with; specific consolidated compliance reporting was not found in the sample. - **1115 Waivers**: Mississippi operates 1115 waivers (e.g., family-planning) that may carry tailored PA provisions. ## 4. How MS runs its own program Mississippi operates a hybrid FFS + managed-care system: - **Fee-for-Service (FFS)**: Handles services outside MCO networks; fiscal agent processes claims and manages PA. DOM publishes the centralized procedure-code list and pharmacy criteria packets. - **Managed Care (MississippiCAN)**: Multiple MCOs serving the state; each manages its own medical-service PA, while pharmacy remains under state control (carve-in). - **Behavioral Health**: Largely processed through MCOs with minor FFS exceptions. - **1115 Waivers**: Provide additional coverage/support for specific populations. (A named fiscal-agent transition — ACS-Inc → Conduent/Gainwell, with a current MESA system reference — appears in the synthesis but is partly template-injected; verify the agent chain.) ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Centralized Procedure-Code Spreadsheet**: A single master XLSX of PA-required codes is the defining FFS-non-pharmacy feature. - **State Pharmacy Criteria PDFs**: Per-drug/per-class packets. - **MESA Provider Portal**: One-stop hub for requirements, submission, and status. ### What's Missing/Uncertain: - **CMS-0057-F specifics**: No consolidated compliance documentation found. - **Gold Card bill number**: Unverified. - **Foster-care program**: No dedicated MCO program noted. - **Per-document codes**: Some criteria packets omit CPT/HCPCS codes. Overall, Mississippi's prior-authorization system centers on a centralized procedure-code spreadsheet (FFS non-pharmacy) plus state pharmacy criteria packets, delivered through the MESA portal. Mississippi is not a WISeR participant.