Mississippi Medicaid – MS Admin. Code 23 Part 225 Chapter 1 – Telehealth Services
Title 23: Division of Medicaid
Part 225: Telemedicine
Chapter 1: Telehealth Services
Rule 1.1: Definitions
The Division of Medicaid defines telemedicine as a method which uses electronic information
and communication equipment to supply and support health care when remoteness disconnects
patients and links primary care physicians, specialists, providers, and beneficiaries which
includes, but is not limited to, telehealth services, remote patient monitoring services,
teleradiology services, store-and-forward and continuous glucose monitoring services.
A. The Division of Medicaid defines telehealth services as the delivery of health care by an
enrolled Mississippi Medicaid provider, through a real-time communication method, to a
beneficiary who is located at a different site. The interaction must be:
- Live,
- Interactive, and
- Audiovisual.
B. The Division of Medicaid defines the originating site, also referred to as the spoke site, as the
physical location of the beneficiary at the time the telehealth service is provided.
C. The Division of Medicaid defines the distant site, also referred to as the hub site, as the
physical location of the provider delivering the telehealth service at the time the telehealth
service is provided.
D. The Division of Medicaid defines the telepresenter as medical personnel who: - Is a Mississippi Medicaid provider, or employed by a Mississippi Medicaid provider and
directly supervised by the provider or an appropriate employee of the provider if the
medical personnel’s license or certification requires supervision, - Is trained to use the appropriate technology at the originating site,
- Is able to facilitate comprehensive exams under the direction of a distant site practitioner
who is, or is employed by, a Mississippi Medicaid provider. - Must remain in the exam room for the entirety of the exam unless otherwise directed by
the distant site provider for the appropriate treatment of the beneficiary, and - Must act within the scope of their practice, license, or certification.
E. The Division of Medicaid defines direct supervision as the provider’s, or an appropriate
employee of the provider, presence in the office suite and immediately available to furnish
assistance and direction throughout the performance of the telehealth service but does not
require the provider to be physically present in the room when the telehealth service is
delivered.
Source: 42 C.F.R. § 410.78; Miss. Code Ann. § 43-13-121; SPA 15-003.
History: Revised eff. 08/01/2020; New to correspond with SPA 15-003 (eff. 01/01/2015) eff.
07/01/2015.
Rule 1.2: Provider Enrollment
A. Providers of telehealth services must comply with all requirements set forth in Miss. Admin.
Code Part 200, Rule 4.8 for all providers in addition to the provider specific requirements
below: - National Provider Identifier (NPI), verification from National Plan and Provider
Enumeration System (NPPES), - Copy of current licensure card or permit, and
- Verification of social security number using a social security card, military ID or a
notarized statement signed by the provider noting the social security number. The name
noted on the verification must match the name noted on the W-9.
B. Providers of telehealth services must be an enrolled Mississippi Medicaid provider acting
within their scope-of-practice and license or medical certification or Mississippi Department
of Health (MDSH) certification and in accordance with state and federal guidelines,
including but not limited to, authorization of prescription medications at both the originating
and distant site.
C. The Division of Medicaid requires that providers utilize telehealth technology sufficient to
provide real-time interactive communications that provide the same information as if the
telehealth visit was performed in-person. Equipment must also be compliant with all
applicable provisions of the Health Insurance Portability and Accountability Act (HIPAA).
D. The use and delivery of telemedicine services does not alter a provider’s privacy obligations
under federal and/or state law and a provider or entity operating telehealth services that
involve protected health information (PHI) must meet the same Health Insurance Portability
and Accountability Act (HIPAA) requirements the provider or entity would for a service
provided in person.
Source: 42 C.F.R. § 410.78; The Health Insurance Portability and Accountability Act (HIPAA)
of 1996 (as amended by the Genetic Information Nondiscrimination Act (GINA) of
2008 and the Health Information Technology for Economic and Clinical Health Act
(HITECH Act), Title XIII of Division A, and Title IV of Division B of the American
Recovery and Reinvestment Act (ARRA) 0f 2009) and its implementing regulations,
including 45 C.F.R. Parts 160 and 164, Subparts A and E (Privacy Rule), and Subparts
A and C (Security Rule); Miss. Code Ann. § 43-13-121; SPA 20-0010; SPA 15-003.
History: Revised eff. 08/01/2020; Revised eff. 07/01/2018; Added Miss. Admin. Code Part 225,
Rule 1.2.C.6. eff. 05/01/2016; New to correspond with SPA 15-003 (eff. 01/01/2015)
eff. 07/01/2015.
Rule 1.3: Covered Services
A. The Division of Medicaid covers medically necessary telehealth services as a substitution for
an in-person visit for consultations, office visits, and/or outpatient visits when all the required
medically appropriate criteria is met which aligns with the description of the Current
Procedural Terminology (CPT) evaluation and management (E&M) and Healthcare Common
Procedure Coding System (HCPCS) guidelines.
B. The Division of Medicaid covers telehealth services at the following locations: - At the following originating sites:
a) Office of a physician or practitioner,
b) Outpatient Hospital (including a Critical Access Hospital (CAH)),
c) Rural Health Clinic (RHC),
d) Federally Qualified Health Center (FQHC),
e) Community Mental Health/Private Mental Health Centers,
f) Therapeutic Group Homes,
g) Indian Health Service Clinic,
h) School-based clinic,
i) School which employs a school nurse,
j) Inpatient hospital setting, or
k) Beneficiary’s home. - At the distant site the following provider types are allowed to render telehealth services:
a) Physicians,
b) Physician Assistants,
c) Nurse Practitioners,
d) Psychologists,
e) Licensed Clinical Social Workers (LCSWs),
f) Licensed Professional Counselors (LPCs),
g) Board Certified Behavior Analysts (BCBAs) or Board Certified Behavior Analyst-
Doctorals (BCBA-Ds),
h) Community Mental Health Centers (CMHCs),
i) Private Mental Health Centers,
j) Federally Qualified Health Centers (FQHCs),
k) Rural Health Centers (RHCs), or
l) Physical, occupational or speech therapy.
C. The Division of Medicaid requires a telepresenter who meets the requirements of Miss.
Admin Code Part 225, Rule 1.1.C. at the originating site as determined by the Division.
Source: 42 C.F.R. § 410.78; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 15-003.
History: Revised eff. 07/01/2021; Revised eff. 08/01/2020; New to correspond with SPA 15-003
(eff. 01/01/2015) eff. 07/01/2015.
Rule 1.4: Non-Covered Services
The Division of Medicaid does not:
A. Cover a telehealth service if that same service is not covered in an in-person setting.
B. Cover a separate reimbursement for the installation or maintenance of telehealth hardware,
software and/or equipment, videotapes, and transmissions.
C. Cover early and periodic screening, diagnosis, and treatment (EPSDT) well child visits
through telehealth.
D. Cover physician or other practitioner visits through telehealth for: - Non-established beneficiaries, and/or
- Level VI or V visits.
E. Consider the following as telehealth services: - Telephone conversations,
- Chart reviews;
- Electronic mail messages;
- Facsimile transmission;
- Internet services for online medical evaluations, or
- Communication through social media, or
- Any other communication made in the course of usual business practices including, but
not limited to,
a) Calling in a prescription refill, or
b) Performing a quick virtual triage.
F. Cover the installation or maintenance of any telecommunication devices or systems.
Source: 42 C.F.R. § 410.78; Miss. Code Ann. § 43-13-121; SPA 15-003.
History: Revised eff. 07/01/2021; Revised eff. 08/01/2020; New to correspond with SPA 15-003
(eff. 01/01/2015) eff. 07/01/2015.
Rule 1.5: Reimbursement
A. The Division of Medicaid reimburses the provider at the originating site the Mississippi
Medicaid telehealth originating site facility fee for telehealth services per completed
transmission, in addition to a separately identifiable covered service if performed. - The following providers are eligible to receive the originating site facility fee for
telehealth services per transmission:
a) The office of a physician or practitioner,
b) An outpatient hospital, including a Critical Access Hospital (CAH),
c) A Rural Health Clinic (RHC),
d) A Federally Qualified Health Center (FQHC),
e) A Community Mental Health/Private Mental Health Center,
f) A Therapeutic Group Home,
g) An Indian Health Service Clinic,
h) A School-Based Clinic, or
i) School which employs a nurse. - The originating site provider can only bill for an encounter or Evaluation and
Management (E&M) visit if a separately identifiable covered service is performed. - An inpatient hospital’s originating site fee is included in the All Patient
Refined/Diagnosis Related Group (APR-DRG) payment.
B. The Division of Medicaid reimburses all providers delivering a medically necessary
telehealth service at the distant site at the current applicable Mississippi Medicaid fee-forservice
rate or encounter for the service provided. The provider must include the appropriate
modifier on the claim indicating the service was provided through telehealth.
C. Providers delivering simultaneous distant and originating site services to a beneficiary are
reimbursed: - The current applicable Mississippi Medicaid fee-for-service rate for the medical
service(s) provided, and - Either the originating or distant site facility fees, not both, except for RHC, FQHC and
CMHC when such services are appropriately provided by the same organization.
Source: 42 C.F.R. § 410.78; Miss. Code Ann. §§ 43-13-117, 43-13-121; SPA 15-003.
History: Revised eff. 07/01/2021; Revised eff. 08/01/2020; Revised eff. 07/01/2018; Added
Miss. Admin. Code Part 225, Rule 1.5.B.2.f) eff. 05/01/2016; New to correspond with
SPA 15-003 (eff. 01/01/2015) eff. 07/01/2015.
Rule 1.6: Documentation
The provider must document the same information as for a comparable in-person service and be
maintained at both the originating and distant site of the telehealth services provided including,
but not limited to:
A. Signed consent for treatment using telehealth,
B. Medically appropriate reason telehealth was utilized to provide services,
C. Beneficiary’s presenting diagnosis and symptoms,
D. Specific name/type of all diagnostic studies and results/findings of the studies, and
E. Plan of Care.
Source: Miss. Code Ann. § 43-13-121.
History: Revised eff. 08/01/2020; New to correspond with SPA 15-003 (eff. 01/01/2015) eff.
07/01/2015.
Rule 1.7: Procedures during States of Emergency
The Mississippi Division of Medicaid will allow additional coverage of telehealth services
during a state of emergency as declared by either the Governor of Mississippi or the President of
the United States. Details of enhanced services include the following that will terminate at the
discretion of the Mississippi Division of Medicaid:
A. A beneficiary may seek treatment utilizing telehealth services from an originating site not
listed in the Mississippi Medicaid State Plan regarding Telehealth (SPA 3.1-A Introductory
Pages 1 and 2). These emergency exceptions include the following: - A beneficiary’s residence may be an originating site without prior approval by the
Division of Medicaid. - Health care facilities not listed in the State Plan wishing to act as an originating site must
first be granted approval by the Division of Medicaid before rendering originating site
telehealth services.
B. A beneficiary may seek treatment utilizing telehealth services from a distant site provider not
listed under Miss. Admin. Code Part 223, Rule 1.3. as determined by the Division of
Medicaid.
C. Telehealth services are expanded to include use of telephonic audio that does not include
video when authorized by the State of Mississippi.
D. A beneficiary may use the beneficiary’s personal telephonic land line in addition to a cellular
device, computer, tablet, or other web camera-enabled device to seek and receive medical
care in a synchronous format with a distant-site provider.
E. When the beneficiary receives services in the home, the requirement for a telepresenter to be
present may be waived.
F. The Division of Medicaid requires that providers utilize telehealth technology compliant
with all applicable provisions of the Health Insurance Portability and Accountability Act
(HIPAA) or otherwise compliant with guidance or notifications regarding the HIPAA
Privacy and Security Rules issued by the Office of Civil Rights of the U.S. Department of
Health and Human Services that is specific to the State of Emergency.
Source: Miss. Code Ann. §§ 43-13-117, 43-13-121; MS SPA 20-0015.
History: Revised eff. 08/01/2020; New Rule to correspond with SPA 20-0015 (eff. 03/01/2020)
eff. 03/20/2020.
Part 225 Chapter 2: Remote Patient Monitoring Services
Rule 2.1: Definitions
A. The Division of Medicaid defines telemedicine as a method which uses electronic
information and communication equipment to supply and support health care when
remoteness disconnects patients and links primary care physicians, specialists, providers, and
beneficiaries which includes, but is not limited to, telehealth services, remote patient
monitoring services, teleradiology services, store-and-forward and continuous glucose
monitoring services.
B. The Division of Medicaid defines remote patient monitoring as using digital technologies to
collect medical and other forms of health data from individuals in one location and
electronically transmit that information securely to healthcare providers in a different
location for interpretation and recommendation.
Source: Miss. Code Ann. § 43-13-121.
History: New eff. 07/01/2015.
Rule 2.2: General Provider Information
A. Providers of remote patient monitoring services must comply with all requirements set forth
in Miss. Admin. Code Part 200, Rule 4.8 for all providers in addition to the provider specific
requirements below: - National Provider Identifier (NPI), verification from National Plan and Provider
Enumeration System (NPPES), - Copy of current licensure card or permit, and
- Verification of social security number using a social security card, military ID or a
notarized statement signed by the provider noting the social security number. The name
noted on the verification must match the name noted on the W-9.
B. Remote patient monitoring services must be delivered by an enrolled Medicaid provider
acting within their scope-of-practice and license and in accordance with state and federal
guidelines.
C. The use and delivery of remote patient monitoring services does not alter a covered
provider’s privacy obligations under federal/and or state law and a provider or entity
operating telehealth services that involve protected health information (“PHI”) must meet the
same HIPAA requirements the provider or entity would for a service provided in person.
D. Providers of remote patient monitoring services must have protocols in place to address all of
the following: - A mechanism for monitoring, tracking and responding to changes in a beneficiary’s
clinical condition, and - A process for notifying the prescribing physician of significant changes in the
beneficiary’s clinical signs and symptoms.
Source: The Health Insurance Portability and Accountability Act (“HIPAA”) of 1996 (as
amended by the Genetic Information Nondiscrimination Act (“GINA”) of 2008 and the
Health Information Technology for Economic and Clinical Health Act (“HITECH
Act”), Title XIII of Division A, and Title IV of Division B of the American Recovery
and Reinvestment Act (“ARRA”) 0f 2009) and its implementing regulations, including
45 C.F.R. Parts 160 and 164, Subparts A and E (“Privacy Rule”), and Subparts A and C
(“Security Rule”); Miss. Code Ann. § 43-13-121.
History: New eff. 07/01/2015.
Rule 2.3: Covered Services
A. The Division of Medicaid covers remote patient monitoring of devices when medically
necessary, ordered by a physician, physician assistant or nurse practitioner which includes,
but not limited to: - Implantable pacemakers,
- Defibrillators,
- Cardiac monitors,
- Loop recorders,
- External mobile cardiovascular telemetry, and
- Continuous glucose monitors.
B. The Division of Medicaid covers remote patient monitoring, for disease management when
medically necessary, prior authorized by the Utilization Management/Quality Improvement
Organization (UM/QIO), Division of Medicaid or designee, ordered by a physician,
physician assistant, or nurse practitioner for a beneficiary who meets the following criteria: - Has been diagnosed with one (1) or more of the chronic conditions as defined by the
Centers of Medicare and Medicaid Services (CMS) which include, but are not limited to:
a) Diabetes,
b) Congestive Heart Failure (CHF),
c) Chronic Obstructive Pulmonary Disease (COPD),
d) Heart disease,
e) Mental health, and
f) Sickle cell. - Is capable of using the remote patient monitoring equipment and transmitting the
necessary data or has a willing and able person to assist in completing electronic
transmission of data.
C. Prior Authorization must include the following: - An order for remote patient monitoring services, signed and dated by the prescribing
physician, - A plan of care, signed and dated by the prescribing physician, that includes transmission
frequency and duration of monitoring requested, - Beneficiary’s diagnosis and risk factors that qualify the beneficiary for remote patient
monitoring, - Attestation that the beneficiary is cognitively intact and able to operate the equipment or
has a willing and able person to assist in completing transmission of data, and - Attestation that the beneficiary is not receiving duplicative services via disease
management.
D. Remote patient monitoring services must be provided in the beneficiary’s private residence.
Source: Miss. Code Ann. §§ 43-13-117, 43-13-121, 83-9-353.
History: Revised eff. 07/01/2021, Revised eff. 01/01/2021; New eff. 07/01/2015.
Rule 2.4: Non-Covered Services
The Division of Medicaid does not cover remote patient monitoring for disease management as
outlined in Miss. Admin. Code Part 225, Rule 2.3.B. for a beneficiary who is a resident of an
institution that meets the basic definition of a hospital or long-term care facility.
Source: Miss. Code Ann. § 43-13-121.
History: New eff. 07/01/2015.
Rule 2.5: Reimbursement
A. The Division of Medicaid reimburses for remote patient monitoring: - Of devices when billed with the appropriate code, and
- For disease management:
a) A daily monitoring rate for days the beneficiary’s information is reviewed.
b) Only one (1) unit per day is allowed, not to exceed thirty-one (31) days per month.
c) An initial visit to install the equipment and train the beneficiary may be billed as a
set-up visit.
d) Only one set-up is allowed per episode even if monitoring parameters are added after
the initial set-up and installation.
e) Only one (1) daily rate will be reimbursed regardless of the number of
diseases/chronic conditions being monitored.
B. The Division of Medicaid does not reimburse for the duplicate transmission or interpretation
of remote patient monitoring data.
Source: Miss. Code Ann. § 43-13-121.
History: New eff. 07/01/2015.
2.6: Documentation
The provider must document the remote patient monitoring service the same as for a comparable
in person service which includes, but is not limited to:
A. The monitoring equipment meets all of the following requirements: - Capable of monitoring any data parameters included in the plan of care,
- Food and Drug Administration (FDA) Class II hospital-grade medical device, and
- Capable of accurately measuring and transmitting beneficiary glucose and/or blood
pressure data.
B. Qualified staff installed the remote patient monitoring equipment necessary to monitor and
transmit the data according to the beneficiary’s care plan.
C. Clinical data was provided to the beneficiary’s primary care physician or his/her designee.
D. Monitoring of the beneficiary’s clinical data was not duplicated by any other provider.
E. Beneficiary’s home environment has the necessary space and connections for installation and
transmission of data.
Source: Miss. Code Ann. § 43-13-121.
History: New eff. 07/01/2015.
Part 225 Chapter 3: Teleradiology Services
Rule 3.1: Definitions
The Division of Medicaid defines telemedicine as a method which uses electronic information
and communication equipment to supply and support health care when remoteness disconnects
patients and links primary care physicians, specialists, providers, and beneficiaries which
includes, but is not limited to, telehealth services remote patient monitoring services,
teleradiology services, store-and-forward and continuous glucose monitoring services.
A. The Division of Medicaid defines store-and-forward as telecommunication technology for
the transfer of medical data from one (1) site to another through the use of a camera or
similar device that records or stores an image which is transmitted or forwarded via
telecommunication to another site for teleconsultation and includes, but is not limited to,
teleradiology services.
B. The Division of Medicaid defines a: - Teleradiology service as the electronic transmission of radiological images, known as
store-and-forward images, from one (1) location to another for the purposes of
interpretation. - Consulting provider as a licensed physician who interprets the radiological image, at the
distant site and who must be licensed in the state within the United States in which he/she
practices. - Distant site, also referred to as a hub site, as the location of the teleradiology consulting
provider. - Referring provider as a licensed physician, physician assistant, or nurse practitioner who
orders the radiological service and who must be licensed in the state within the United
States in which he/she practices. - Originating site, also referred to as the spoke site, as the location where the beneficiary is
receiving the teleradiology service.
A. Store-and-forward as telecommunication technology for the transfer of medical data from
one (1) site to another through the use of a camera or similar device that records or stores an
image which is transmitted or forwarded via telecommunication to another site for
teleconsultation and includes, but is not limited to, teleradiology. - The transmission cost as the cost of the line charge incurred during the time of the
transmission of a telehealth service.
Source: Miss. Code Ann. § 43-13-121.
History: Moved from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.
Rule 3.2: General Provider Information
A. Providers of teleradiology services must comply with all requirements set forth in Miss.
Admin. Code Part 200, Rule 4.8 for all providers in addition to the provider specific
requirements below: - National Provider Identifier (NPI), verification from National Plan and Provider
Enumeration System (NPPES), - Copy of current licensure card or permit, and
- Verification of social security number using a social security card, military ID or a
notarized statement signed by the provider noting the social security number. The name
noted on the verification must match the name noted on the W-9.
B. Teleradiology services must be delivered by an enrolled Medicaid provider acting within
their scope-of-practice and license and in accordance with state and federal guidelines.
C. The use and delivery of teleradiology services does not alter a covered provider’s privacy
obligations under federal/and or state law and a provider or entity operating telehealth
services that involve protected health information (“PHI”) must meet the same HIPAA
requirements the provider or entity would for a service provided in person.
D. The teleradiology service provider must ensure: - Images are provided without clinically significant loss of data from image acquisition
through transmission to final image display to enable the consulting provider to
accurately interpret the image, - Equipment used provides image quality appropriate to the clinical need.
- The radiologic examination at the originating site be performed at the originating site by
qualified personnel:
a) Trained in the performance of the specified radiological service,
b) Operating within the licensure requirements of the state in which the service is being
performed, and
c) Under the supervision of a qualified licensed physician. - Teleradiology systems provide network and software security protocols to protect the
confidentiality of a beneficiary’s identification and imaging data with measures
implemented to safeguard the data and to ensure data integrity against intentional or
unintentional corruption of the data.
Source: The Health Insurance Portability and Accountability Act (“HIPAA”) of 1996 (as
amended by the Genetic Information Nondiscrimination Act (“GINA”) of 2008 and the
Health Information Technology for Economic and Clinical Health Act (“HITECH
Act”), Title XIII of Division A, and Title IV of Division B of the American Recovery
and Reinvestment Act (“ARRA”) 0f 2009) and its implementing regulations, including
45 C.F.R. Parts 160 and 164, Subparts A and E (“Privacy Rule”), and Subparts A and C
(“Security Rule”); Miss. Code Ann. § 43-13-121.
History: Moved with Revisions from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.
Rule 3.3: Covered Services
The Division of Medicaid covers:
A. One (1) technical and one (1) professional component for each teleradiology procedure only
for providers enrolled as a Mississippi Medicaid provider and when there are no
geographically local radiologist providers to interpret the images.
B. The technical component of the radiological service is covered at the originating site.
C. The professional component of the radiological service is covered at the distant site.
Source: Miss. Code Ann. § 43-13-121.
History: Moved with Revisions from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.
Rule 3.4: Non-Covered Services
The Division of Medicaid does not cover:
A. The transmission cost or any other associated cost of teleradiology,
B. Both the technical and professional component of teleradiology services for one (1) provider,
or
C. One (1) provider billing for services performed by another provider.
Source: Miss. Code Ann. § 43-13-121.
History: Moved from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.
Rule 3.5: Reimbursement
A. The Division of Medicaid reimburses for: - The technical component of the radiological service at the originating site for only
providers enrolled as a Mississippi Medicaid provider. - The professional component of the radiological service at the distant site only for
providers enrolled as a Mississippi Medicaid provider.
B. If a hospital chooses to bill for purchased or contractual teleradiology services, the service
must be billed under a physician group provider number only.
Source: Miss. Code Ann. § 43-13-121.
History: Moved from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.
Rule 3.6: Documentation
A. Teleradiology documentation must include, but not limited to: - At the originating site:
a) The reason teleradiology was utilized to deliver the service including there was no
local radiologists to interpret the images,
b) Date(s) of service,
c) Beneficiary demographic information,
d) Signed consent for treatment, if applicable,
e) Medical history,
f) Beneficiary’s presenting complaint,
g) Diagnosis, and
h) Specific name/type of all diagnostic studies and results/findings of the studies. - At the distant site:
a) Date(s) of service,
b) Beneficiary demographic information,
c) Medical history,
d) Beneficiary’s presenting complaint,
e) Diagnosis,
f) Specific name/type of all diagnostic studies and results/findings of the studies, and
g) Radiological images.
Source: Miss. Code Ann. § 43-13-121.
History: Moved from Miss. Admin. Code Part 220, Rule 1.4. eff. 07/01/2015.
Part 225 Chapter 4: Continuous Glucose Monitoring Services
Rule 4.1: Definitions
A. The Division of Medicaid defines telemedicine as a method which uses electronic
information and communication equipment to supply and support health care when
remoteness disconnects patients and links primary care physicians, specialists, providers, and
beneficiaries which includes, but is not limited to, telehealth services remote patient
monitoring services, teleradiology services, store-and-forward, and continuous glucose
monitoring services.
B. The Division of Medicaid defines a continuous glucose monitoring service as: - The download, retrospective review and interpretation of blood glucose values by a
physician, physician’s assistant or nurse practitioner when captured for more than
seventy-two (72) hours on a continuous glucose monitor system, and - Adjunct monitoring, not an alternative, to traditional self-monitoring of blood glucose
levels, supplying additional information on glucose trends that are not available from
self-monitoring.
Source: Miss. Code Ann. § 43-13-121.
History: New eff. 07/01/2015.
Rule 4.2: General Provider Information
A. Providers of continuous glucose monitoring services must comply with all requirements set
forth in Miss. Admin. Code Part 200, Rule 4.8 for all providers in addition to the provider
specific requirements below: - National Provider Identifier (NPI), verification from National Plan and Provider
Enumeration System (NPPES), - Copy of current licensure card or permit, and
- Verification of social security number using a social security card, military ID or a
notarized statement signed by the provider noting the social security number. The name
noted on the verification must match the name noted on the W-9.
B. Continuous glucose monitoring services must be delivered by an enrolled Medicaid provider
acting within their scope-of-practice and license and in accordance with state and federal
guidelines.
C. The use and delivery of continuous glucose monitoring services does not alter a covered
provider’s privacy obligations under federal/and or state law and a provider or entity
operating telehealth services that involve protected health information (“PHI”) must meet the
same HIPAA requirements the provider or entity would for a service provided in person.
Source: The Health Insurance Portability and Accountability Act (“HIPAA”) of 1996 (as
amended by the Genetic Information Nondiscrimination Act (“GINA”) of 2008 and the
Health Information Technology for Economic and Clinical Health Act (“HITECH
Act”), Title XIII of Division A, and Title IV of Division B of the American Recovery
and Reinvestment Act (“ARRA”) 0f 2009) and its implementing regulations, including
45 C.F.R. Parts 160 and 164, Subparts A and E (“Privacy Rule”), and Subparts A and C
(“Security Rule”); Miss. Code Ann. § 43-13-121.
History: New eff. 07/01/2015.
Rule 4.3: Covered Services
A. The Division of Medicaid covers: - A continuous glucose monitoring (CGM) service when medically necessary, prior
authorized by the UM/QIO, Division of Medicaid or designee, ordered by the physician
who is actively managing the beneficiary’s diabetes and the beneficiary meets all of the
following criteria:
a) Has an established diagnosis of type I or type II diabetes mellitus that is poorly
controlled as defined below:
1) Unexplained hypoglycemic episodes,
2) Nocturnal hypoglycemic episode(s),
3) Hypoglycemic unawareness and/or frequent hypoglycemic episodes leading to
impairments in activities of daily living,
4) Suspected postprandial hyperglycemia,
5) Recurrent diabetic ketoacidosis, or
6) Unable to achieve optimum glycemic control as defined by the most current
version of the American Diabetes Association (ADA).
b) Be able, or have a caregiver who is able, to hear and view CGM alerts and respond
appropriately.
c) Has documented self-monitoring of blood glucose at least four (4) times per day.
d) Requires insulin injections three (3) or more times per day or requires the use of an
insulin pump for maintenance of blood glucose control.
e) Requires frequent adjustment to insulin treatment regimen based on blood glucose
testing results,
f) Had an in-person visit with the ordering physician within six (6) months prior to
ordering to evaluate their diabetes control and determined that criteria (1-4) above are
met,
g) Has an in-person visit every six (6) months following the prescription of the CGM to
assess adherence to the CGM regimen and diabetes treatment plan. - CGM service only when the blood glucose data is obtained from a Federal Drug
Administration (FDA) approved Class III, durable medical equipment (DME) medical
device for home use.
B. The Division of Medicaid does not require the provider to have a face-to-face office visit
with the beneficiary to download, review and interpret the blood glucose data.
Source: 42 U.S.C. § 1395x(n); Miss. Code Ann. § 43-13-121.
History: Revised eff. 07/01/2021; New eff. 07/01/2015.
Rule 4.4: Non-Covered Services
A. The Division of Medicaid does not cover non-medically necessary non-durable medical
equipment (DME) CGM devices that are not approved by the Food and Drug Administration
(FDA) and do not comply with the FDA and American Diabetes Association (ADA)
recommendations.
B. The Division of Medicaid does not cover non-DME devices including, but not limited to,
smartphones, tablets, or personal computers.
Source: Miss. Code Ann. §§ 43-13-117, 43-13-121.
History: Revised eff. 07/01/2021; New eff. 07/01/2015.
Rule 4.5: Reimbursement
A. The Division of Medicaid reimburses for: - One (1) retrospective review and interpretation of blood glucose values per month, and
- A one (1) time device hook-up which includes beneficiary education.
B. The Division of Medicaid does not reimburse for a separate Evaluation and Management
(E&M) visit unless a separately identifiable service is performed.
Source: Miss. Code Ann. § 43-13-121.
History: New eff. 07/01/2015.
Rule 4.6: Documentation
Continuous glucose monitoring (CGM) service documentation must include, but is not limited
to:
A. The beneficiary and/or care giver is capable of operating the continuous glucose monitoring
system,
B. The beneficiary: - Has an established diagnosis of type I or type II diabetes mellitus that is poorly controlled
as defined in Miss. Admin. Code Part 225, Rule 4.3.A.1.a), - Requires three (3) insulin injections per day, or use of an insulin pump, for maintenance
of blood glucose control, - Requires regular self-monitoring of at least four (4) times a day,
- Requires frequent adjustment to insulin treatment regimen based on blood glucose testing
results, - Had an in-person visit with the ordering physician within six (6) months prior to ordering
to evaluate their diabetes control and determined that criteria (1-4) above are met, - Has an in-person visit every six (6) months following the prescription of the CGM to
assess adherence to the CGM regimen and diabetes treatment plan.
C. The CGM is Food and Drug Administration (FDA) Class III medical device and is capable of
accurately measuring and transmitting beneficiary blood data.
Source: 42 U.S.C. § 1395x(n); Miss. Code Ann. §§ 43-13-117, 43-13-121.
History: Revised eff. 07/01/2021; New eff. 07/01/2015.