CHAPTER 51

Short Title

This regulation shall be known and may be cited as the Uniform Health Claim Form Regulation.

Section 1. Purpose

  The purpose and intent of this regulation is to standardize the forms used in the billing and reim- bursement of health care, reduce the number of forms utilized, increase efficiency in the reimbursement of health care through standardization and encourage the use of and prescribe a timetable for implemen- tation of electronic data interchange of health care expenses and reimbursement.

Section 2. Authority

The statutory authority for this regulation is W.S. 26-15-127. It is adopted pursuant to the Wyo- ming Administrative Procedure Act.

Section 3. Definitions As used in this regulation:

1. (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.
2. (b) “CDT Procedure Codes” means the current dental terminology prescribed by the Ameri- can Dental Association.
3. (c) “CPT Codes” means the physicians current procedural terminology, published by the American Medical Association.
4. (d) “HCFA” means the Health Care Financing Administration of the U.S. Department of Health and Human Services.
5. (e) “HCFA Form 1450” means the health insurance claim form maintained by HCFA for use by institutional care practitioners.
6. (f) “HCFA Form 1500” means the health insurance claim form maintained by HCFA for use by health care practitioners.

7. (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:

   1. (i) “HCPCS Level 1 Codes” which are the AMA’s CPT codes and modifiersfor pro- fessional services and procedures.
   2. (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.
   3. (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.
8. (h) “Health Care Practitioner” means:
9. (i) A chiropractor licensed under W.S. 33-10-101.
10. (ii) A corporation or partnership of health care practitioners defined in this section.
11. (iii) A dentist licensed under W.S. 33-15-101.
12. (iv) A nurse licensed under W.S. 33-21-119.
13. (v) An optometrist licensed under W.S. 33-23-101.
14. (vi) A physician licensed under W.S. 33-26-101.
15. (vii) A podiatrist licensed under W.S. 33-9-101.
16. (viii) A psychologist licensed under W.S. 33-27-101.
17. (ix) A speech, physical, respiratory or occupational therapist licensed under W.S. 33- 25-101; W.S. 33-33-101 and W.S. 33-40-101.
18. (x) A home health care provider W.S. 35-2-901.
19. (i) “ICD-CM Codes” means the diagnosis and procedure codes in the International Classifi- cation of Diseases, clinical modifications published by the U.S. Department of Health and Human Ser- vices.

20. (j) “Institutional Care Practitioner” means:

    1. (i) A hospice;
    2. (ii) A hospital;
    3. (iii) A skilled nursing facility, extended care facility, intermediate care facility, conva- lescent nursing home, and personal care facility; and
    4. (iv) A home health care provider.
21. (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.
22. (l) “J5xx Form” means the uniform dental claim form approved by the American Dental Association for use by dentists.
23. (m) “NDC”, National Drug Code, means the identifying drug number maintained by the Food and Drug Administration (FDA).
24. (n) “NSF”, National Standard Format, means a flat file format standard for submissionof health care claims electronically.
25. (o) “Revenue Codes” means the codes established for use by institutional care practi- tioners by the National Uniform Billing Committee.

Section 4. Applicability and Scope

1. (a) Except as otherwise specifically provided, the requirements of this regulation apply to is- suers, health care practitioners, and institutional care practitioners.
2. (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.
3. (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 writ- ten contract between the health care practitioner or institutional care practitioner and issuer.

Section 5. Requirements for Use of HCFA Form 1500

1. (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 addi- tion to any other explanatory information used to bill the patient when requested by the patient.

2. (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:

   1. (i) HCPCS Codes;
   2. (ii) ICD-9-CM Codes;
   3. (iii) In the case of Workers’ Compensation, specific body part and other information used for the coding of charges; and
   4. (iv) NDC codes for pharmaceuticals supplied by physicians and home health care providers.

3. (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:

   1. (i) When the procedure code used describes a treatment or service that is not other- wise classified; or
   2. (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.
4. (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.
5. (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 al- ready defined by the HCPCS code. If not defined by either HCPCS or in line 19, units will be assumed to be days of treatment.
6. (f) Health care practitioners shall provide the unique physician identification number, as as- signed by HCFA, in box 17a and the federal tax identification number or social security number to com- plete Item 25 of the HCFA Form 1500, as required by the HCFA instructions.

Section 6. Requirements for Use of HCFA Form 1450

1. (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. In- stitutional 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.

2. (b) Issuers may only require institutional care practitioners to use the following coding sys- tem for the initial filing of claims for health care services:

   1. (i) ICD-9-CM Codes;
   2. (ii) Revenue Codes;
   3. (iii) HCPCS Codes; and
   4. (iv) The information outlined in Section 5 of this regulation, if the charges include di- rect services furnished by a health care practitioner, and the direct services are not covered by the in- structions for the HCFA form 1450.
3. (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.

Section 7. Requirements for Use of J5xx ADA Form; CDT Proce- dure Codes

1. (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 re- quested by the patient.
2. (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.

Section 8. General Provisions

1. (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.

2. (b) Issuers shall accept forms submitted in compliance with this regu- lation for the processing of claims.

3. (c) Health care practitioners, institutional care practitioners and issuers shall:

   1. (i) Use and accept the most current editions of the HCFA Form 1500, HCFA Form 1450, or J5xx Form and most current instructions for these forms in the billing of patients or their representatives and filing claims with issuers.
   2. (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 proce- dures required under this regulation.

Section 9. Mandatory Electronic Format

​​​​​​​Unless otherwise provided by federal or state law, issuers that elect to re- ceive claims or elect to send payments by electronic means shall, by January 1, 1997, support the National Standard Format (NSF) for electronic media claims (EMC) 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 suc- cessors become the required standard formats.

Section 10. Separability

​​​​​​​ If any provision of this regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regu- lation and the application of the provision to other persons or circumstances shall not be affected thereby.