Wyo. Code R. 048-0037-11
Medicaid
Chapter 11: Medical Supplies and Equipment
Effective Date: 06/18/2019 to 01/30/2023
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.11.06182019
Section 1. Authority. This rule is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. § 42-4-101 through W.S. § 42-4-306 and the Wyoming Administrative Procedures Act at W.S. § 16-3-101 through W.S. § 16-3-115.
Section 2. Purpose and Applicability. This chapter establishes the standards and procedures for the provision of and payment for medical supplies and equipment. Any person, facility, or agency that furnishes medical supplies or equipment and seeks Medicaid reimbursement for doing so shall be subject to these rules. These rules shall apply to all medical supplies and equipment provided on or after the effective date of the rule.
(a) For any code, standard, rule or regulation incorporated by reference in these rules:
(i) The Department of Health has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules.
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of this section.
(iii) The incorporated code, standard, rule or regulation is maintained at the Department of Health and is available for public inspection and copying at cost at the same location.
(b) Each rule incorporated by reference and can be found at http://soswy.state.wy.us/rules/ and is further identified as follows:
(i) Referenced in Section 5 is Wyoming Medicaid Rule, Chapter 1 – Definitions, adopted by the Department of Health and effective on November 7, 2011.
(ii) Referenced in Sections 6, 7, 8, 11, 13 and 16 is Wyoming Medicaid Rule, Chapter 3 – Provider Participation, adopted by the Department of Health and effective on December 16, 1998.
(iii) Referenced in Sections 14 and 17 is Wyoming Medicaid Rule, Chapter 4 – Administrative Hearings, adopted by the Department of Health and effective on November 7, 2011.
(iv) Referenced in Section 9 is Wyoming Medicaid Rule, Chapter 10 – Pharmaceutical Services, adopted by the Department of Health and effective on November 1, 2005.
(v) Referenced in Sections 15 and 18 is Wyoming Medicaid Rule, Chapter 16 – Program Integrity, adopted by the Department of Health and effective on November 7, 2011.
(vi) Referenced in Section 14 is Wyoming Medicaid Rule, Chapter 35 – Medicaid Benefit Recovery, adopted by the Department of Health and effective on March 25, 2005.
(vii) Referenced in Section 6 is Medicare DMEPOS requirements, 42 CFR 424.57, dated November 24, 2014, found at http://www.ecfr.gov/cgi-bin/text-idx?SID=37cacefe56fa419c5fb06444817f3c5f&mc=true&node=se42.3.424_157&rgn=div8
(a) General methodology. As specified in this Chapter, the Department reimburses for medical supplies and equipment pursuant to the Medicaid fee schedule.
(b) The Department may issue manuals, bulletins, or both, to interpret the provisions of this Chapter. Such manuals and bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions of these rules and regulations govern over the provisions contained in manuals or bulletins.
(c) The incorporation by reference of any external standard is intended to be the incorporation of that standard as it is in effect on the effective date of these rules and regulations.
(a) Except as otherwise specified in this Chapter or Chapter 1, the terminology used in this Chapter is the standard terminology and has the standard meaning used in health care, Medicaid, and Medicare.
(b) The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indicates that such is the intent, words in the singular number shall include the plural and vice versa.
(c) For the purpose of these rules, the following shall apply:
(i) “Certification of medical necessity.” A written certification by the prescribing practitioner certifying that the equipment is medically necessary, for items identified by the Department.
(A) The Department may, from time to time, designate equipment as requiring a certification of medical necessity based on clinical consultation with health professionals, CMS guidelines, and other appropriate sources. The Department shall disseminate to providers a current list of the equipment which requires a certification of medical necessity through Provider Manuals or Provider Bulletins; and (B) A certification of medical necessity is in addition to a physician's order.
(ii) "Disposable Medical Supplies (supplies)." Supplies prescribed by a practitioner which have a medical purpose, are specifically related to the active treatment or therapy of the recipient for a medical illness or physical condition and which are consumable and/or expendable and non-durable. Supplies must meet the definition of medically necessary and shall be prescribed by an appropriate licensed practitioner.
(iii) "Excess payments." Medicaid funds received by a provider, to which the provider is not entitled for any reason, including payments which exceed the Medicaid allowable payment. "Excess payments" includes, but is not limited to:
(A) Overpayments;
(B) Payments made as a result of system errors;
(C) Payments for services furnished to a non-recipient;
(D) Payments for non-covered services furnished to a recipient;
(E) Payments for services which are not documented and/or supported by medical records and/or financial records;
(F) Payments for services for which admission certification has been denied or withdrawn;
(G) Payments which exceed a provider's usual and customary charge, unless otherwise permitted by the Department's rules.
(iv) "Misuse." 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 utilization by persons other than that for whom the use is prescribed or intended according to Department records.
(v) "Practitioner's order." A written order which:
(A) Is on a practitioner's personalized prescription pad or the practitioner's letterhead, either of which must contain the practitioner's printed name;
(B) Contains the practitioner's personal signature (a stamped signature or a practitioner's signature written by another person are not acceptable), and the date it is signed;
(C) Contains one or more diagnosis codes or a statement of the condition which necessitates the medical supplies or equipment, and an estimate, in days, months, or years, of the time it will be needed;
(D) In the case of durable medical equipment or a prosthetic device, specifies the additional or optional features which will be separately billed using HCPCS codes;
(E) In the case of medical supplies, specifies the quantity and frequency of use, the frequency of changes, and the estimated duration of medical necessity; and
(F) Is reviewed and re-signed by the practitioner at least once per year.
(vi) 'Prescribed.' Ordered by a practitioner to be furnished to a client to treat a medical condition. Medical supplies or durable medical equipment which are prescribed must be on a practitioner's order.
(vii) 'Prosthetic Devices.' Replacement, corrective, or supportive devices prescribed by a practitioner to:
(A) Artificially replace a missing portion of the body;
(B) Prevent or correct physical deformity or malfunction; or
(C) Support a weak or deformed portion of the body.
(viii) 'Service area.' The State of Wyoming and the following cities or towns: Craig, Colorado; Idaho Falls, Montpelier and Pocatello, Idaho; Billings and Bozeman, Montana; Kimball and Scottsbluff, Nebraska; Belle Fourche, Custer, Deadwood, Rapid City and Spearfish, South Dakota; and Ogden and Salt Lake City, Utah.
(a) Compliance with Chapter 3. An individual or entity that wishes to receive Medicaid funds for medical supplies, durable medical equipment or prosthetic devices furnished to a recipient must meet the requirements of Chapter 3.
(b) Eligible providers.
(i) A pharmacy; or
(ii) A non-pharmacy that has a current, valid business license as required by the laws of the State of Wyoming or the State where the business is located.
(c) Provider Responsibilities. Providers shall be responsible for the delivery of the prescribed durable medical equipment, prosthetic device, or supplies. After delivery, if an item is determined to be inappropriate or incorrect, the provider is responsible for retrieving the durable medical equipment or supplies within five (5) working days after being notified of the problem by the client or the Department. Claims for items known to be awaiting pickup by the provider cannot be billed to the Medicaid program. 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. Providers shall be responsible for confirmation of continued need for disposable supplies by contact with the client or client's caretaker prior to shipment of supplies. Continued need shall be confirmed by a current prescription which contains a statement of length of need.
(d) Compliance with 42 CFR 424.57. An individual or entity which wishes to receive Medicaid funds for services must meet the requirements to be a DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies) supplier and must follow the procedures and comply with the standards as set forth in 42 CFR 424.57, except that the term 'Medicaid' shall replace the term 'Medicare,' and 'Department' shall replace 'CMS'.
(a) Compliance with Chapter 3. A provider of medical supplies or equipment must comply with the record-keeping requirements of Chapter 3.
(b) Documentation of medical necessity. The medical records must substantiate the medical necessity of the medical supplies or equipment prescribed to a client, including the client's diagnosis and prognosis, the estimated duration of the condition which necessitates the medical supplies or equipment, the nature and extent of the client's functional limitations, other therapeutic interventions which have been tried, and their results, and, if required, a copy of the certification of medical necessity.
Section 8. Verification of client data. A provider of medical supplies must comply with the verification of client data requirements of Chapter 3.
(a) The medical supplies specified in (b) are covered services if:
(i) Medically necessary;
(ii) Prescribed; and
(iii) Provided to a client for use by the client in the client's residence or other community location.
(b) Covered services.
(i) Ambulation devices;
(ii) Bathroom equipment;
(iii) Bedroom equipment;
(iv) Diabetic supplies, other than insulin and insulin syringes, which may be covered pursuant to Chapter 10;
(v) Lifts;
(vi) Orthopedic devices;
(vii) Ostomy care products;
(viii) Respiratory care accessories, supplies, and related devices;
(ix) Oxygen delivery systems;
(x) Stockings and elastic supports;
(xi) Syringes and needles;
(xii) Transcutaneous or neuromuscular electrical nerve simulators;
(xiii) Urinary care products;
(xiv) Wheelchairs and scooters; and
(xv) Lymphedema pumps.
Section 10. Limited services. Medical supplies are limited to the time-period for which they are prescribed, which may not exceed one month.
(a) Incorporation of Chapter 3. Prior authorization of medical supplies and equipment shall be governed by the prior authorization requirements of Chapter 3.
(b) Medical supplies that require prior authorization.
(i) The Department may designate medical supplies or equipment that require prior authorization.
(ii) In designating medical supplies that require prior authorization, the Department shall consider the:
(A) Cost of the service;
(B) Potential for over-utilization of the medical supplies; and
(C) Availability of lower cost alternatives.
(iii) The Department may disseminate a list of medical supplies and equipment that require prior authorization to providers through manuals, bulletins or other methods deemed appropriate for provider communication.
(iv) The failure to obtain prior authorization shall result in denial of Medicaid payment for the service.
Section 12. Medicaid allowable payment. The Medicaid allowable payment for medical supplies and equipment shall be pursuant to the Medicaid fee schedule.
Section 13. Submission and Payment of claims.
(a) Submission of claims. Submission and payment of claims shall be pursuant to the provisions of Chapter 3.
(b) Documentation. Claims for specified equipment must include a certification of medical necessity, evidence of prior authorization, or both.
Section 14. Third-party liability.
(a) Submission of claims. Claims for which third-party liability exists shall be submitted in accordance with Chapters 4 and 35.
(b) Medicaid payment. 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. Recovery of excess payments and overpayments.
(a) The Department may recover excess payments pursuant to Chapter 16.
(b) The Department may recover overpayments pursuant to Chapter 16.
Section 16. Reconsideration. A provider may request that the Department reconsider a decision to recover excess payments or overpayments. The request for reconsideration, the reconsideration, and any administrative hearing shall be pursuant to the reconsideration provisions of Chapter 3.
(a) Clients. A client may request an administrative hearing pursuant to Chapter 4 regarding the termination, reduction or denial of covered services.
(b) Procedures. A request for an administrative hearing must be made in accordance with Chapter 4, and the hearing shall be held pursuant to Chapter 4.
Section 18. Disposition of recovered funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of its various provisions.
Section 20. Superseding effect. When promulgated, this Chapter supersedes all prior rules or policy statements issued by the Department, including provider manuals and provider bulletins, which are inconsistent with this Chapter.
Section 21. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in effect.