Health, Department of

Medicaid

Chapter 11: MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS

Effective Date: 01/30/2023 to Current

Rule Type: Current Rules & Regulations

Reference Number: 048.0037.11.01302023

CHAPTER 11

MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS

Section 1. Authority. The Wyoming Department of Health (Department) promulgates this Chapter pursuant to the Wyoming Medical Assistance and Services Act at Wyoming Statute 42-4-101 through -124.

Section 2. Purpose and Applicability.

(a) The Department adopts this Chapter to govern the standards and procedures for the provision of, and payment for, Medicaid medical supplies, durable medical equipment, orthotics and prosthetics by enrolled providers and suppliers.

(b) This Chapter applies to all clients and providers of any furnished Medicaid medical supplies, durable medical equipment, orthotics, or prosthetics.

(c) The Department may issue manuals and bulletins to interpret this Chapter. Such manuals and bulletins shall be consistent with and reflect the rules contained in this Chapter. The provisions contained in manuals or bulletins shall be subordinate to this Chapter.

Section 3. Definitions.

(a) Except as otherwise specified in Wyoming Medicaid Rules Chapter 1, or as defined herein, the terminology used in this Chapter is the standard terminology and has the standard meaning used in health care, Medicaid, and Medicare.

(b) 'Certification of medical necessity' means a written certification by the prescribing practitioner certifying that the equipment is medically necessary, as required for certain items identified by the Department.

(c) 'Misuse' means the intentional utilization of equipment, prosthetic device, or supplies in a manner not prescribed or recommended resulting in the need for repairs or replacement, or the utilization by persons other than the client for whom the use is prescribed or intended according to Department records.

(d) 'Practitioner's order' means a written order on the practitioner's personalized prescription pad or letterhead that contains the practitioner's printed name, the practitioner's personal physically-made signature, and the date it was signed.

Section 4. Provider Enrollment and Participation.

(a) No provider or supplier of medical supplies, durable medical equipment, or prosthetics furnished to a client shall receive Medicaid reimbursement unless enrolled with Medicaid pursuant to Wyoming Medicaid Rules Chapter 3.

(b) A provider or supplier of medical supplies, durable medical equipment, or prosthetics furnished to a client shall meet the provider participation requirements of Wyoming Medicaid Rule Chapter 3.

(c) A provider or provider entity shall provide proof of Medicare certification as a durable medical equipment, prosthetics, orthotics, and supplies (DMPOS) supplier prior to Medicaid reimbursement.

Section 5. Eligible providers.

(a) A pharmacy;

(b) A practitioner's office;

(c) A non-pharmacy supplier with a current, valid business license as required by the laws of the State of Wyoming or the state where the business is located.

Section 6. Provider records.

(a) A provider of medical supplies, durable medical equipment, or prosthetics must comply with the record-keeping requirements of Wyoming Medicaid Rules Chapter 3.

(b) The provider's medical records must substantiate the medical necessity of the medical supplies, durable equipment, or prosthetics prescribed for a client, including: the client's diagnosis and prognosis; the estimated duration of the condition which necessitates the medical supplies or durable medical equipment; the nature and extent of the client's functional limitations; other therapeutic interventions which have been tried and their results; and a copy of the certification of medical necessity, and request for prior authorization, if applicable.

Section 7. Verification of Client Data. A provider of medical supplies must comply with the verification of client data requirements of Wyoming Medicaid Rules Chapter 3.

Section 8. General Coverage Provisions.

(a) The medical supplies, durable medical equipment, and prosthetics described in Sections 9 and 10 are a covered service if they are:

1. (i) Medically necessary, as defined in Wyoming Medicaid Rules Chapter 1;
2. (ii) Appropriate and effective for the client's medical needs;
3. (iii) Timely, considering the nature and present medical condition of the client;
4. (iv) Provided by a provider with appropriate credential;
5. (v) The least expensive, appropriate alternative available;
6. (vi) Not considered experimental or investigational;

(vii) An effective and appropriate use of Medicaid funds; (viii) Suitable for use in the client's home or any non-institutional setting in which normal life activities take place; (ix) Generally not useful in the absence of an illness, injury, or disability; (x) Provided to correct or accommodate a physiological disorder of physical condition, or generally used primarily for a medical purpose; and, (xi) Prescribed using a practitioner's order which:

(A) Includes one or more diagnosis codes, or a statement of the condition which necessitates the medical supplies, durable medical equipment or prosthetics, and an estimate in days, months, or years of the time it will be needed;

(B) If durable medical equipment or a prosthetic device, specifies the additional or optional features which will be separately billed using HCPCS codes;

(C) If medical supplies, specifies the quantity and frequency of use, the frequency of changes, the estimated duration of medical necessity, and is reviewed and re-signed by the practitioner at least once per year.

(b) The Department may designate certain durable medical equipment as requiring a certification of medical necessity in addition to a practitioner's order based on clinical consultation with health professionals, CMS guidelines, and other appropriate sources. The Department shall disseminate to providers a current list of the durable medical equipment which requires a certification of medical necessity through applicable provider manuals and bulletins.

(c) Providers shall be responsible for the delivery of the prescribed medical supplies, durable medical equipment, and prosthetics.

(d) After delivery, if an item is determined to be inappropriate or incorrect, the provider is responsible for retrieving the medical supplies or durable medical equipment within five (5) working days after being notified of the problem by the client or the Department.

(i) Claims for items known to be awaiting pickup by the provider cannot be billed to the Medicaid program.

(ii) If billing occurs prior to notice that pickup is necessary, the provider shall submit an adjustment within twenty (20) working days following the date of pickup.

(e) Providers shall be responsible for confirmation of continued need for disposable supplies by contact with the client or client's caregiver prior to shipment of supplies. Continued need shall be confirmed by a current prescription which contains the duration of medication necessity.

Section 9. Covered services.

(a) The following items are covered services if provided in compliance with the general requirements of Section 8:

1. (i) Ambulation devices;
2. (ii) Lactation equipment and supplies;
3. (iii) Diabetic Supplies, other than insulin and insulin syringes, which may be covered pursuant to Medicaid Rules Chapter 10;
4. (iv) Enteral and Parenteral Nutrition - other Medical foods;
5. (v) Home infusion supplies;
6. (vi) Hospital beds and equipment;
7. (vii) Infusion pumps and supplies;
8. (viii) Medication Dispensers or equipment;
9. (ix) Orthopedic devices;
10. (x) Ostomy care products;
11. (xi) Oxygen delivery systems and supplies;
12. (xii) Pacemaker monitors, self-contained;
13. (xiii) Paraffin or Sitz baths;
14. (xiv) Phototherapy light and supplies;
15. (xv) Pneumatic compressors and appliances;
16. (xvi) Post-surgery recovery equipment or wound care;
17. (xvii) Prosthetics;
18. (xviii) Respiratory care accessories, supplies, and related devices;
19. (xix) Speech generating devices;
20. (xx) Stockings and elastic supports;
21. (xxi) Suction pumps;

(xxii) Syringes and needles;

(xxiii) Traction equipment;

(xxiv) Transfer or lift equipment;

(xxv) Transcutaneous or neuromuscular electrical nerve simulators;

(xxvi) Urinary care products;

(xxvii) Wheelchairs and scooters; and

(xxviii) Other medical equipment and supplies determined to be medically necessary and approved by the Department.

(b) Covered disposable medical supplies are limited to a one-month supply.

(c) A client may request an administrative hearing regarding the termination, reduction, or denial of covered services in accordance with Wyoming Medicaid Rules Chapter 4.

Section 10. Authorization Requests for Non-Covered Services

(a) Authorization may be requested for any piece of durable medical equipment, supply, or prosthetic that is considered a non-covered item as described in the Medicaid Durable Medical Equipment Manual. Documentation must be submitted that demonstrates the item meets the criteria listed in Section 8(a).

(b) Fully completed requests shall be acted upon within 30 days of receipt. Wyoming Medicaid shall notify providers and clients of the grant or denial of the request for coverage. If denied, clients shall be notified of their right to request an administrative hearing pursuant to Wyoming Medicaid Rules Chapter 4.

Section 11. Prior authorization.

(a) The Department may designate medical supplies or durable medical equipment that require prior authorization. The failure to obtain prior authorization shall result in denial of Medicaid payment for the service. Prior authorization of medical supplies and durable medical equipment shall be governed by the prior authorization requirements of Wyoming Medicaid Rules Chapter 3.

(b) In designating medical supplies or durable medical equipment that require prior authorization, the Department shall consider the:

(i) Cost of the service;

(ii) Potential for over-utilization of the medical supplies; and (iii) Availability of lower cost alternatives.

(c) The Department may disseminate a list of medical supplies and durable medical equipment that require prior authorization to providers through manuals, bulletins or other methods deemed appropriate for provider communication.

Section 12. Medicaid allowable payment. The Medicaid allowable payment for medical supplies, durable medical equipment, and prosthetics shall be pursuant to the Medicaid fee schedule.

Section 13. Submission and Payment of claims. Submission and payment of claims shall be pursuant to the provisions of Wyoming Medicaid Rules Chapter 3.

Section 14. Third-party liability.

(a) Claims for which third-party liability exists shall be submitted in accordance with Wyoming Medicaid Rules Chapter 35.

(b) The Medicaid payment for a claim for which third party liability exists shall be the difference between the Medicaid allowable payment and the third party payment. In no case shall the Medicaid payment exceed the payment otherwise allowable pursuant to this Chapter.

Section 15. Audits. Audits shall be subject to the provisions of Wyoming Medicaid Rules Chapter 16.

Section 16. Overpayments. The Department shall recover overpayments pursuant to Wyoming Medicaid Rules Chapter 16. In addition to using its own internal processes for recovery of overpayments, the Department may refer a matter involving suspected overpayments to the Medicaid Fraud Control Unit at any time.