Ask for the Hours You Will Actually Deliver. Mississippi's MCO Says So in Writing.

Most payer policies tell you what they will not pay for. Mississippi's TrueCare policy tells you how to write the request.

Under the prior authorization criteria in MM-1477, effective May 1, 2026, the hours you ask for must be

“based on the member's specific needs, not on a general program structure”

and must satisfy both of the following: treatment “is provided at the lowest level of intensity appropriate to the member's clinical needs and goals,” with

“the number of hours requested reflecting the actual number of hours intended to be provided.”

That last clause is sharper than it looks

Requesting more than you intend to deliver is common practice and usually defended as prudent — ask high, absorb the cut, protect the schedule. This policy makes the gap itself the defect. A practice that requests 30 hours and intends to staff 25 has filed a request that fails on its own terms, independently of whether 30 is clinically justifiable.

The companion clause does the same work from the other side. “Lowest level of intensity appropriate” means the standard is not whether the hours are defensible but whether a smaller number would also have been. And “not on a general program structure” is aimed squarely at the practice of assigning a tier and fitting the child to it.

Fourteen exclusions, and four of them are unusual

Section VII lists what will not be reimbursed. The routine ones are there — experimental methods, education services under IDEA, vocational services under Section 110 of the Rehabilitation Act, custodial care, services not documented in the treatment plan. Four are worth checking your caseload against:

• “Treatment for symptoms and behaviors not part of core symptoms diagnosis.” Read against a real plan of care, this is the one that bites. Toileting, sleep, feeding and safety work are routinely on ABA plans and are routinely justified as quality-of-life goals rather than as core autism symptoms. If your goal documentation does not tie a target back to the diagnosis, this exclusion is the hook.
• “Treatment solely for the benefit of the family, caregiver, or therapist.” Caregiver training is covered — this policy requires documented caregiver participation or documented barriers to it — but a goal whose stated beneficiary is the household rather than the member sits outside.
• “Shadowing, para-professional, companion services, personal training or life coaching in any setting.” The phrase “in any setting” closes the school gap that other states address by naming schools. It does not matter where the technician is standing.
• “Services are more costly than alternative service(s) as likely to produce equivalent diagnostic or therapeutic results.” A cost-effectiveness test applied to a clinical decision, with no stated method for demonstrating equivalence.

Two more are worth a glance: services provided by family or household members are excluded, and so is duplicative therapy addressing the same behavioral goals with the same techniques “including services under an IEP.”

What you have to file, and on what clock

Authorization runs in 6-month periods. Where continuation is requested with inadequate or no demonstrable progress within a six-month period, the policy requires a documented assessment of the reasons, and modified interventions — naming changed techniques, increased caregiver training, more time on specific targets, resolution of barriers, newly identified co-occurring disorders, and revised goals.

A diagnostic evaluation older than 24 months needs a provider letter describing clinical symptoms present within the past year. The named diagnostic tools are ADOS, ADI-R and CARS-2, and diagnosis must come from a psychologist, child neurologist or developmental pediatrician among others.

On who may deliver: services must come from a Mississippi-licensed LBA or LABA under LBA supervision, and behavior technicians “must be certified as Registered Behavior Technicians (RBT) and listed with the respective State Licensure Board under a supervising LBA.”

The limits

We covered CareSource's Georgia policy on September 7, and MM-1477's discontinuation standard is the same instrument: no meaningful progress across two successive six-month authorization periods, measured by standardized assessments. That is one payer applying one framework across its markets, and nothing here is new on that point.

The exclusions list is prefaced as applying to reimbursement, and the policy states plainly that a Medical Policy Statement “do[es] not ensure an authorization or payment of services” and that where it conflicts with the plan contract, the contract controls. The policy also cites the Mental Health Parity and Addiction Equity Act, stating that coverage for a behavioral health disorder “will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions” — which is the payer's own language and worth keeping to hand.

What you must know or do

• Compare a month of authorized hours against a month of delivered hours for your Mississippi members. If there is a standing gap, your requests do not meet the written standard, and the fix is in how you request rather than in how you staff.
• Read your next three plans of care for goals that are not tied to the diagnosis. Toileting, sleep and safety targets need a documented line back to core symptoms. The exclusion does not say these cannot be treated — it says treatment for behaviors outside the core diagnosis is not reimbursed, and the difference lives entirely in your written rationale.
• Check whether any Mississippi technician time could read as shadowing or companion work. The exclusion says “in any setting,” so a school placement is not what determines it. What the session notes describe is.
• Confirm every Mississippi RBT is listed with the state licensure board under a named supervising LBA. BACB certification alone does not satisfy the policy's wording.
• If a request is cut on cost-equivalence grounds, ask what the equivalent alternative is. The policy asserts the test without describing how equivalence is established, and that is a reasonable question to put in writing on appeal.