Wyo. Code R. 048-0037-11
Medicaid
Chapter 11: Medical Supplies and Equipment
Effective Date: 02/16/2005 to 02/08/2017
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.11.02162005
This rule is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W. S. 42-4-101 et seq. and the Wyoming Administrative Procedures Act at W. S. 16-3-101 et seq.
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 its effective date.
(a) General methodology. As specified in this Chapter, the Department pays 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 contained in manuals or bulletins shall be subordinate to the provisions of these rules and regulations.
(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.
Except as otherwise specified, the terminology used in this Chapter is the standard terminology and has the standard meaning used in health care, Medicaid, and Medicare.
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. Throughout these rules gender pronouns are used interchangeably. The drafters have attempted to utilize each gender pronoun in equal numbers, in random distribution. Words in each gender include individuals of the other gender.
For the purpose of these rules, the following shall apply:
(a) “Abuse”. The intentional destruction of or damage to equipment which results in the need for repairs or replacement.
(b) “Certification of medical necessity.” A written certification by the prescribing practitioner certifying that the equipment is medically necessary, for items identified by the Department.
(i) 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
(ii) A certification of medical necessity is in addition to a physicians order.
(c) “CMS.” The Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services, its agent, designee or successor.
(d) “Chapter 1.” Chapter 1, Medicaid Administrative Hearings, of the Wyoming Medicaid rules.
(e) “Chapter 3.” Chapter 3, Provider Participation, of the Wyoming Medicaid rules.
(f) “Chapter 4.” Chapter 4, Third Party Liability, of the Wyoming Medicaid rules.
(g) “Chapter 10.” Chapter 10, Pharmaceutical Services, of the Wyoming Medicaid rules.
(h) “Chapter 12.” Chapter 12, Home Health Services, of the Wyoming Medicaid rules.
(i) “Chapter 16.” Chapter 16, Medicaid Program Integrity, of the Wyoming Medicaid rules.
(j) “Chapter 35.” Chapter 35, Medicaid Benefit Recovery, of the Wyoming Medicaid rules.
(k) “Chapter 39.” Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid rules.
(l) “Claim.” A request by a provider for Medicaid payment for services provided to a recipient.
(m) “Covered services.” Services which are Medicaid reimbursable as specified in this Chapter.
(n) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(o) 'DFS.' The Wyoming Department of Family Services, its agent, designee or successor.
(p) 'Diagnosis codes.' Diagnosis codes as contained in the International Classification of Diseases, 9th Revision, Clinical Modification ('ICD-9-CM'), which is incorporated by this reference. The ICD-9-CM is authorized by CMS and is available from the United States Government Printing Office, Washington, D.C. 20402.
(q) '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.
(r) 'Emergency.' The sudden onset of a medical condition, manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:
(i) Placing the patient's health in serious jeopardy;
(ii) Serious impairment of bodily functions; or
(iii) Serious dysfunction of any bodily organ or part.
(s) '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:
(i) Overpayments;
(ii) Payments made as a result of system errors;
(iii) Payments for services furnished to a non-recipient;
(iv) Payments for non-covered services furnished to a recipient;
(v) Payments for services which are not documented and/or supported by medical records and/or financial records;
(vi) Payments for services for which admission certification has been denied or withdrawn;
(vii) Payments which exceed a provider’s usual and customary charge, unless otherwise permitted by the Department’s rules.
“HCPCS.” The Healthcare Common Procedure Coding System of CMS.
(u) “Local trade area.” The geographic area surrounding the recipient’s residence, including portions of states other than Wyoming, commonly used by other persons in the same area to obtain services.
(v) “Medicaid.” Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act. “Medicaid” includes any successor or replacement program enacted by Congress or the Wyoming Legislature.
(w) “Medical necessity” or “medically necessary.” Medical necessity for disposable medical supplies, equipment, prosthetic devices which are necessary in the treatment, prevention, or alleviation of an illness, injury, condition or disability. Determination of medical necessity shall be made in accordance with the following criteria:
(i) It is prescribed by a physician or other licensed practitioner;
(ii) It is a reasonable, appropriate, and effective method for treating the client’s illness, injury, condition or disability.
(iii) The expected use is in accordance with current medical standards or practices;
(iv) Is cost effective;
(v) Provides for a safe environment or situation for the client;
(vi) For the purposes stated, utilization is not experimental, not investigational, and is generally accepted by the medical community; and
(vii) Its primary purpose may not be to enhance the personal comfort of the recipient, nor to provide convenience for the recipient or the recipient’s caregiver.
“Medicaid allowable payment.” The maximum Medicaid reimbursement for covered services as specified by this Chapter or other Medicaid rules of the Department.
“Medicaid fee schedule.” The Medicaid fee schedule established pursuant to Chapter 3, which is incorporated by this reference.
(z) “Mid-level practitioner.” An advanced practitioner of nursing or a physician’s assistant who is licensed by the Wyoming Board of Nursing, the Wyoming State Board of Medicine, or a similar agency in another state.
(aa) “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.
(bb) “Neglect.” Failure to maintain equipment or a prosthetic device as specified by the manufacturer’s or provider’s instructions, which results in the need to repair or replace the equipment or prosthetic device.
(cc) “Nursing facility.” A nursing facility as defined by 42 U.S.C. § 1396r(a), which is incorporated by this reference. “Nursing facility” includes an intermediate care facility for the mentally retarded (ICF/MR), or a distinct part of a hospital which is designated to provide nursing facility services.
(dd) “Overpayments.” “Overpayments” as defined in Chapter 39, which definition is incorporated by this reference
(ee) “Pharmacy.” A business that is licensed as a pharmacy by the Wyoming State Board of Pharmacy or a similar board or agency in another state.
(ff) “Physician.” A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a similar board or agency in another state.
(gg) “Practitioner.” A health professional licensed by an agency or board of the State of Wyoming or a similar agency in another state who is acting within the scope of his or her licensure. “Practitioner” includes physicians and mid-level practitioners.
“Practitioner’s order.” A written order which:
(i) Is on a practitioner’s personalized prescription pad or the practitioner’s letterhead, either of which must contain the practitioner’s printed name;
(ii) 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,
(iii) 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;
(iv) 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;
(v) 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 (vi) Is reviewed and re-signed by the practitioner at least once per year.
(ii) “Prescribed.” Ordered by a practitioner to be furnished to a recipient to treat a medical condition. Medical supplies or durable medical equipment which are prescribed must be on a practitioner’s order.
(jj) “Prior authorization.” Prior authorization means a written, faxed or electronic approval from the Department that permits payment or coverage of a service that is covered only by such authorization. Prior authorization must be done according to the procedures and standards set forth in Section 10.
(kk) “Prosthetic Devices.” Replacement, corrective, or supportive devices prescribed by a practitioner to:
(i) Artificially replace a missing portion of the body;
(ii) Prevent or correct physical deformity or malfunction; or
(iii) Support a weak or deformed portion of the body.
(ll) “Provider.” A provider as defined by Chapter 3, which definition is incorporated by this reference.
(mm) “Recipient.” A person who has been determined eligible for Medicaid.
(nn) “Residence.” The place, other than a nursing facility, a recipient uses as his or her primary dwelling place, and intends to continue to use indefinitely for that purpose.
(oo) “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.
(pp) “Services.” Medical supplies, durable medical equipment, or prosthetic devices.
(qq) “Usual and customary.” The provider’s charge to the general public for the same or similar services.
(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, which requirements are incorporated by this reference.
(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 recipient 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 a credit 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 recipient or recipient’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,” which is incorporated by this reference.
(a) Compliance with Chapter 3. A provider of medical supplies or equipment must comply with the record-keeping requirements of Chapter 3, which are incorporated by this reference.
(b) Documentation of medical necessity. The medical records must substantiate the medical necessity of the medical supplies or equipment prescribed to a recipient, including the recipient’s diagnosis and prognosis, the estimated duration of the condition which necessitates the medical supplies or equipment, the nature and extent of the recipient’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 7. Verification of recipient data. A provider of medical supplies must comply with the verification of recipient data requirements of Chapter 3, which are incorporated by this reference.
(a) The medical supplies specified in (b) are covered services if:
(i) Medically necessary;
(ii) Prescribed; and
(iii) Provided to a recipient for use by the recipient in the recipient's residence.
(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 9. 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, which are incorporated by this reference.
(b) Medical supplies that require prior authorization.
(i) The Department may, from time to time, designate medical supplies or equipment that require prior authorization.
(ii) In designating medical supplies that require prior authorization, the Division 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 shall disseminate a list of medical supplies and equipment that require prior authorization to providers through Manuals or Bulletins.
(iv) The failure to obtain prior authorization shall result in denial of Medicaid payment for the service.
Section 11. Medicaid allowable payment. The Medicaid allowable payment for medical supplies and equipment shall be pursuant to the Medicaid fee schedule.
(a) Submission and payment of claims shall be pursuant to the provisions of Chapter 3, which are incorporated by this reference.
(b) Claims for specified equipment must include a certification of medical necessity, evidence of prior authorization, or both.
(a) Submission of claims. Claims for which third-party liability exists shall be submitted in accordance with Chapters 4 and 35, which are incorporated by this reference.
(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 14. Recovery of excess payments and overpayments.
(a) The Department may recover excess payments pursuant to Chapter 16 or Chapter 39.
(b) The Department may recover overpayments pursuant to Chapter 16 or Chapter 39.
Section 15. 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, which are incorporated by this reference.
Section 16. Administrative hearing.
(a) Recipients. A recipient may request an administrative hearing pursuant to Chapter 1 regarding the termination, reduction or denial of covered services.
(b) Procedures. A request for an administrative hearing must be made in conformance with Chapter 1, and the hearing shall be held pursuant to Chapter 1.
Section 17. Disposition of recovered funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16, which provisions are incorporated by this reference.
Section 18. Interpretation of Chapter.
(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 19. 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 20. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in effect.