Mississippi Health Study Guide

Mississippi legislated its health policy provisions in detail and almost nothing about claim conduct outside health. That asymmetry organises this chapter. The state’s one statutory claim clock sits in the health article and deviates from the NAIC uniform provision — which is why national courses miss it.

The claim payment clock — 25, 35, and three percent a month

Under Miss. Code Ann. §83-9-5(1)(h), benefits for any loss other than one the policy pays periodically are paid within twenty-five (25) days after receipt of due written proof of loss in the form of a clean claim “where claims are submitted electronically,” and within thirty-five (35) days “where claims are submitted in paper format.”

Now the number people get wrong. The insurer must pay interest “at the rate of three percent (3%) per month” — to the provider where the claim is owed to the provider, to the insured where it is owed to the insured — on benefits that remain unpaid until the claim is settled or adjudicated. Per month. Not 1.5%.

Two details decide most items. The clocks differ: the 25/35 days run from receipt of a clean claim, interest from the day after payment was due. And an unclean claim never starts the payment clock — a clean claim “requires no further information, adjustment or alteration by the provider … or the insured in order to be processed and paid.”

The rest of §83-9-5(1), by subparagraph

(b) Time Limit on Certain Defenses — two years, with “fraudulent misstatements” carved out and never time-barred.

(c) Grace Period — a ladder. Seven days weekly premium, ten monthly, thirty-one for everything else.

(d) Reinstatement — the forty-fifth day after the conditional receipt, where the insurer requires a reinstatement application, unless it has “previously notified the insured in writing of its disapproval.”

(f) Claim Forms — fifteen days. Forms not furnished in time, and the claimant is “deemed to have complied.”

(g) Proofs of Loss — ninety days, from the end of the period for which the insurer is liable, or from the date of the loss.

State continuation — a negative worth marks

Do not write “Mississippi continuation applies only to employers with fewer than 20 employees.” §83-9-51 has no employer-size threshold. Subsection (2) reaches any group policy issued in this state covering employees or members and their dependents for hospital, surgical or major medical insurance on an expense incurred or service basis.

The small-group effect comes from an individual eligibility exclusion at §83-9-51(4), not a headcount. It is unavailable to anyone who is or could be covered by another group arrangement within thirty-one days of termination, whose insurance ended for fraud or nonpayment, who is eligible for COBRA continuation, or who becomes entitled to Medicare. COBRA rules that person out individually; it does not shrink the statute.

The numbers: three consecutive months of prior continuous coverage (3); a contribution “not more than the full group rate” — 100%, not 102% (6); twelve months out (7)(a).

External review — four months, 72 hours, binding with a qualifier

Under the Mississippi Health Carrier External Review Regulation (19 Miss. Admin. Code Pt. 3, Ch. 15, effective 1 January 2013 under Rule 15.19), Rule 15.07(A) allows a standard request within “four (4) months after the date of receipt of a notice of an adverse determination or final adverse determination.” Rendering that as “120 days” is a common error.

Rule 15.08 allows an expedited request on receipt of the determination where the medical-urgency criteria are met; the reviewing organization then decides “in no event more than seventy-two (72) hours.”

Rule 15.10 binds the carrier to the decision “except to the extent the health carrier has other remedies available under applicable State law,” and binds the covered person on the same terms — not final against every remedy.

The statute that is missing

§83-5-35, the unfair trade practices statute, is the frozen 1956 NAIC model: nine enumerated acts, (a) through (i), and no unfair claims settlement practices list. Mississippi has adopted no separate unfair claims act; the NAIC’s model-adoption chart records “no current activity” for Model 900.

That absence is the point. §83-9-5(1)(h) is the only statutory claim clock in Mississippi insurance law and reaches health claims alone; property and casualty claim conduct runs on common-law bad faith. Expect a stem pairing a property claim with health day-counts.

Two closing facts: no ACA Medicaid expansion, and a federally facilitated marketplace, not a state exchange.