Wyo. Code R. 044-0002-51
General Agency, Board or Commission Rules
Chapter 51: Uniform Health Claim Forms Regulation
Effective Date: 07/13/2017 to Current
Rule Type: Current Rules & Regulations
Reference Number: 044.0002.51.07132017
UNIFORM HEALTH CLAIM FORMS REGULATION
Section 1. Authority
This regulation is promulgated pursuant to W.S. §§ 26-2-110, 26-15-127, 16-3-101 et seq.
Section 2. Definitions
As used in this regulation:
(a) "ASC X12N" and any future iterations, standard format means the standards for electronic data interchange within the health care industry developed by the Accredited Standards Committee X12N Insurance Subcommittee of the American National Standards Institute.
(b) "CDT Procedure Codes" means the current dental terminology prescribed by the American Dental Association.
(c) "CPT Codes" means the physicians' current procedural terminology published by the American Medical Association.
(d) "HCFA" means the Health Care Financing Administration of the U.S. Department of Health and Human Services.
(e) "HCFA Form 1450" means the health insurance claim form maintained by HCFA for use by institutional care practitioners.
(f) "HCFA Form 1500" means the health insurance claim form maintained by HCFA for use by health care practitioners.
(g) "HCPCS" means HCFA's Common Procedure Coding System, a coding system which describes products, supplies, procedures and health professional services and includes, the American Medical Associations (AMA's) Physician Current Procedural Terminology codes, alphanumeric codes, and related modifiers. This includes:
(i) "HCPCS Level 1 Codes" which are the AMA's CPT codes and modifiers for professional services and procedures.
(ii) "HCPCS Level 2 Codes" which are national alpha-numeric codes and modifiers for health care products and supplies, as well as some codes for professional services not included in the AMA's CPT.
(iii) "HCPCS Level 3 Codes" which are local alpha-numeric codes and modifiers for items and services not included in HCPCS Level 1 or HCPCS Level 2.
(h) "Health Care Practitioner" means:
(i) A chiropractor licensed under W.S. § 33-10-101 et seq.
(ii) A corporation or partnership of health care practitioners defined in this section.
(iii) A dentist licensed under W.S. § 33-15-101 et seq. (iv) A nurse licensed under W.S. § 33-21-119 et seq. (v) An optometrist licensed under W.S. § 33-23-101 et seq. (vi) A physician licensed under W.S. § 33-26-101 et seq. (vii) A podiatrist licensed under W.S. § 33-9-101 et seq. (viii) A psychologist licensed under W.S. § 33-27-113 et seq.
(ix) A physical, speech and audiology, occupational, or respiratory therapist licensed under W.S. §§ 33-25-101 et seq.; 33-33-101 et seq.; 33-40-101 et seq.; or 33-43-101 et seq.
(x) A home health agency licensed under W.S. § 35-2-901(a).
(i) "ICD-CM Codes" means the diagnosis and procedure codes in the International Classification of Diseases, clinical modifications published by the U.S. Department of Health and Human Services.
(j) "Institutional Care Practitioner" means:
(i) A hospice;
(ii) A hospital;
(iii) A skilled nursing facility, extended care facility, intermediate care facility, convalescent nursing home, or personal care facility; and
(iv) A home health agency.
(k) "Issuer" means an insurance company, fraternal benefit society, health care service plan, health maintenance organization, and third party administrator, and any other public and or private entity reimbursing the costs of health care expenses.
(l) "J5xx Form" means the uniform dental claim form approved by the American Dental Association for use by dentists.
(m) "NDC," National Drug Code, means the identifying drug number maintained by the Food and Drug Administration (FDA).
(n) "NSF," National Standard Format, means a flat file format standard for submission of health care claims electronically.
(o) "Revenue Codes" means the codes established for use by institutional care practitioners by the National Uniform Billing Committee.
(a) Except as otherwise specifically provided, the requirements of this regulation apply to issuers, health care practitioners, and institutional care practitioners.
(b) Nothing in this regulation shall prevent an issuer from requesting additional information that is not contained on the forms required under this regulation to determine eligibility of the claim for payment if required by applicable statutes, rules or regulations or required under the terms of the policy or certificate issued to the claimant.
(c) Nothing in this regulation shall prohibit an issuer, health care practitioner, or institutional care practitioner from using alternative procedures for filing claims as are specified in an existing written contract between the health care practitioner or institutional care practitioner and issuer.
(a) Health care practitioners shall use the HCFA Form 1500 and instructions provided by HCFA for use of the HCFA Form 1500 when filing claims with issuers for professional services. Health care practitioners that bill patients directly shall provide a properly completed HCFA Form 1500 in addition to any other explanatory information used to bill the patient when requested by the patient.
(b) Issuers may only require health care practitioners to use the following coding system and/or descriptors for the initial filing of claims for health care services:
(i) HCPCS Codes;
(ii) ICD-CM Codes;
(iii) In the case of Workers' Compensation, specific body part and other information used for the coding of charges; and
(iv) NDC codes for pharmaceuticals supplied by physicians and home health agency.
(c) Issuers may only require health care practitioners to use other explanations with a code or to furnish additional information with the initial submission of a HCFA Form 1500 under the following circumstances:
(i) When the procedure code used describes a treatment or service that is not otherwise classified; or
(ii) When the procedure code is followed by a CPT modifier. Health care practitioners may use item 19 of the HCFA Form 1500 to explain multiple modifiers, unless item 19 is used for other purposes in accordance with the instructions for this form.
(d) Health care practitioners may use item 19 of the HCFA Form 1500 to indicate the form is an amended version of a form previously submitted to the issuer by inserting the word 'amended' in the space provided.
(e) Health care practitioners billing for services based on the amount of time involved shall define on line 19 the time interval in Item 24 G of the HCFA Form 1500, if the time interval is not already defined by the HCPCS code. If not defined by either HCPCS or in line 19, units will be assumed to be days of treatment.
(f) Health care practitioners shall provide the unique physician identification number, as assigned by HCFA, in box 17a and the federal tax identification number or social security number to complete Item 25 of the HCFA Form 1500, as required by the HCFA instructions.
(a) Institutional care practitioners shall use the HCFA Form 1450 and instructions provided by HCFA for use of the HCFA Form 1450 when filing claims with issuers for health care services. Institutional care providers that bill patients directly shall provide a properly completed HCFA Form 1450 in addition to any other explanatory information used to bill the patient when requested by the patient.
(b) Issuers may only require institutional care practitioners to use the following coding system for the initial filing of claims for health care services:
(iii) HCPCS Codes; and
(iv) The information outlined in Section 5 of this regulation if the charges include direct services furnished by a health care practitioner and the direct services are not covered by the instructions for the HCFA form 1450.
(c) Hospitals may use the HCFA Form 1500 to supplement a HCFA Form 1450 if necessary in billing patients or their representatives or filing claims with issuers for outpatient services.
(a) Dentists shall use the J5xx Form and instructions provided by the American Dental Association for filing claims with issuers for professional services. Dentists that bill patients directly shall provide a properly completed J5xx Form in addition to any other form used to bill the patient when requested by the patient.
(b) Issuers may not require a dentist to use any code other than the CDT Procedure Codes for the initial filing of claims for dental care services, unless the use of supplemental codes are defined and permitted in a written contract between the issuer and dentist. Clearly defined supplemental codes may be used only for procedures not elsewhere defined by CDT Procedure Codes.
(a) Health care practitioners and institutional care practitioners shall file claims in a manner consistent with the requirements of this regulation. Claims filed in paper form shall be printed on 8.5 x 11 inch paper.
(b) Issuers shall accept forms submitted in compliance with this regulation for the processing of claims.
(c) Health care practitioners, institutional care practitioners, and issuers shall:
(i) Use and accept the most current editions of the HCFA Form 1500, HCFA Form 1450, or J5xx Form and the most current instructions for these forms in the billing of patients or their representatives and filing claims with issuers.
(ii) Modify their billing and claim reimbursement practices to encompass the coding changes for all billing and claim filing by the effective date of the changes set forth by the developers of the forms, codes, and procedures required under this regulation.
Unless otherwise provided by federal or state law, issuers that elect to receive claims or elect to send payments by electronic means shall support the NSF for electronic media claims and electronic remittance notice (ERN) as an interim standard format until the American National Standards Institute (ANSI) ASC X12N standard format for the health care claims submission transaction set (837) and the ASC X12N health care claim payment transaction set (835) or their successors become the required standard formats.
These regulations shall be effective upon filing with the Secretary of State.