Wyo. Code R. 048-0037-13
Medicaid
Chapter 13: Community Mental Health
Effective Date: 05/15/1990 to 11/19/2002
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.13.05151990
These rules are promulgated by the Department of Health and Social Services 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 rule establishes the scope of community mental health services covered by Medicaid and the methods and standards for certifying and reimbursing providers of such services.
(a) 'Affiliated physician.' A physician who has a contract with a mental health clinic under which the physician is obligated to supervise the services provided to the clinic's patients that receive mental health clinic services.
(b) 'Audit.' An audit by an independent certified public accountant which includes:
(i) A financial audit which meets the requirements of the Wyoming State Examiner;
(ii) A statement of internal controls and management letter;
(iii) A contract compliance audit if the provider is currently certified; and
(iv) For new providers, results of testing a sample of insurance billings to determine that billings match clinical records entries describing services provided.
(c) 'Business agent.' A person or entity that submits a claim for or receives Medicaid funds on behalf of a provider.
(d) 'Certified.' A provider which has been certified by DCP as being in compliance with DCP's rules establishing Standards for the Operation of Community Mental Health and Substance Abuse Programs, which are hereby incorporated by reference. The rules are available from the Wyoming Secretary of State.
(e) 'Chronically mentally ill.' An individual over nineteen years of age who has been diagnosed by a mental health professional as having a severe, persistent and disabling mental disorder.
(f) 'Claim.' A request by a provider for medicaid payment for covered services provided to a recipient.
(g) 'Clinical assessment.' A written assessment, completed by a mental health or substance abuse professional within seven working days after the first face-to-face therapeutic contact, which includes:
(i) a statement of the presenting problem;
(ii) A summary of the client’s history relating to current problems and to past history of problems and treatment;
(iii) Relevant family and social data;
(iv) Medical data, including current medications, physical illnesses and substance use or abuse;
(v) A diagnostic summary; and
(vi) A DSM diagnosis.
“Clinical records.” Records reflecting the treatment and services provided to a recipient, including:
(i) Documentation of the recipient’s consent to treatment; if the recipient is a minor, consent shall be obtained from the minor’s parent or guardian;
(ii) A fee agreement signed by the recipient or, if the recipient is a minor, the recipient’s parent or guardian, which contains a medical release for billing purposes and advises the recipient of any services not covered by Medicaid for which the recipient may be billed;
(iii) Documentation that the recipient has been informed of his or her client rights;
(iv) A completed copy of the State MIS form with the current diagnosis;
(v) A clinical assessment;
(vi) A treatment plan;
(vii) Separate progress notes for each face-to-face recipient contact and documentation of significant telephone calls and contacts with other persons involved in the recipient’s treatment, except that for recipients in day treatment, a weekly progress note is required;
(viii) A chronological record of medications prescribed, dispensed or both;
(ix) A properly executed release form for each release of information;
(x) Copies of testing, correspondence and interpretation of psychological testing; and
(xi) For any recipient seen for five or more therapeutic contacts, a discharge summary completed within ninety days of the last therapeutic contact.
(i) 'Contract.' A written agreement between a provider and DCP in the form specified by DCP.
(j) 'Covered services.' Mental health clinic services or substance abuse services which are Medicaid reimbursable pursuant to this Chapter.
(k) 'DCP.' The Division of Community Programs of the Department.
(l) 'Department.' The Wyoming Department of Health and Social Services or its designee.
(m) 'DSM.' The most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM), which is hereby incorporated by reference. The DSM is published by the American Psychiatric Association, Washington, D.C., and is available from the publisher.
(n) 'Emergency.' A condition that if not immediately diagnosed or treated could cause a recipient serious physical or mental disability, continuation of severe pain or death.
(o) 'Excess payments.' Medicaid funds received by a provider which exceed the reimbursement limit established by this rule.
(p) 'HCFA.' The Health Care Financing Administration of the United State Department of Health and Human Services.
(q) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(r) 'Medical necessity' or 'medically necessary.' A covered service that is:
(i) Consistent with the recipient's diagnosis and condition;
(ii) Provided in accordance with the prevailing standard or current practice among the provider's peer group;
(iii) Required to meet the medical needs of the recipient and is undertaken for reasons other than the convenience of the recipient or the individual or entity providing the service; and
(iv) Provided in the least costly setting required by the recipient's condition.
(s) 'Medical record.' All documents, in whatever form, including clinical records, in the possession of or subject to the control of the provider which describe the recipient's diagnosis, treatment or condition.
(t) 'Medicare.' The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(u) 'Mental disorder.' A condition defined in the DSM, excluding a sole diagnosis of mental retardation or a specific developmental disorder.
(v) “Mental health clinic.” A facility certified by DCP as a mental health clinic or center.
(w) “Mental health clinic services.” The following services provided by a mental health professional or a substance abuse professional to a recipient pursuant to a treatment plan:
(i) Clinical assessment;
(ii) Day treatment, except for services provided to a recipient with a sole diagnosis of substance abuse disorder;
(iii) Group therapy;
(iv) Family/couples therapy; (v) Individual therapy; or
(vi) Medication management/monitoring.
(x) “Mental health professional.” An individual affiliated with a mental health clinic who is:
(i) A qualified mental health professional as defined by Chapter II, Section 3(b) of the Standards for the Operation of Community Mental Health and Substance Abuse Programs; or
(ii) A registered nurse with two years of supervised experience and training in providing mental health services obtained after becoming an R.N.; or
(iii) A mental health worker as defined by Chapter III, Section 3(c) of the Standards for the Operation of Community Mental Health and Substance Workers:
(A) Has been certified in writing by the director of the mental health clinic as having sufficient training and experience to provide the services of clinical assessment and individual therapy to a general client population as an equivalent of a qualified mental health professional; and
(B) Is actually providing clinical assessment and individual therapy to a general client population.
(y) “Mental health rehabilitative services.” Comprehensive mental health services provided to an individual recipient which will assist the recipient in gaining access to needed community services, to acquire independent living skills, to manage behavior and to manage his or her mental disorder.
(z) “Nursing facility.” A skilled nursing facility, an intermediate care facility or a nursing facility as defined by applicable federal law. “Nursing facility” may include a distinct part of a hospital or institution which is designated to provide nursing facility services.
(aa) “Outpatient.” A person who is not admitted to a hospital as an inpatient and receives services in mental health clinic.
(bb) “Physician.” A person licensed to practice medicine by the Wyoming Board of Medical Examiners.
(cc) “Provider.” A mental health clinic which is certified and has a provider agreement and a contract.
(dd) “Provider agreement.” A written contract between a mental health clinic and the Department in which the mental health clinic agrees to comply with the provisions of the contract and applicable federal and State statutes, rules and regulations as a prerequisite to receiving Medicaid funds for covered services provided to recipients.
(ee) “Quality assurance plan.” A provider’s plan for reviewing medical records to determine the effectiveness and cost-efficiency of mental health clinic services.
“Recipient.” A person who has been determined eligible for Medicaid.
“Residential care.” Non-medical, fully or semi-supervised room, board, and support services for persons with mental disorders.
(hh) “State reimbursement rate.” The payment rate for mental health clinic services established by DCP, recommended to the Wyoming Legislature and approved by Medicaid for use in all DCP contracts.
(ii) “Substance abuse professional.” A person who is affiliated with a mental health clinic and is a qualified substance abuse professional as defined by Chapter III, Section 4(c) of the Standards for the Operation of Community Mental Health and Substance Abuse Programs.
(jj) “Treatment plan.” A written description of expected services outcome, completed by a mental health or substance abuse professional within five working days of the second face-to-face therapeutic contact, and, in the case of mental clinic services, signed by the affiliated physician, which includes:
(i) Specific and objective changes in the recipient’s symptoms and behavior that are expected to result from treatment;
(ii) The methods and activities and their frequency that will be employed by specific persons to implement the treatment; and
(iii) The statement, if mental health clinic services are to be provided, that “I certify that services in this treatment plan are medically necessary and that the client’s treatment goals are appropriate.”
(kk) “Under the supervision of affiliated physician.” The care of each recipient receiving mental health clinic services is provided under the supervision of the affiliated physician who:
(i) Has face-to-face contact with the recipient within the first forty-five days of services and thereafter as the physician specifies;
(ii) Certifies in writing the medical necessity and appropriateness of the prescribed services by signing the clinical assessment and treatment plan;
(iii) Assumes professional responsibility for the services provided under the clinic option;
(iv) Reviews the need for continuing mental health clinic services at least every ninety days and the need for continuing mental health rehabilitative services at least annually; and
(v) Is available for consultation by telephone or is physically present on the premises where the service is being provided.
(II) 'Usual and customary charges.' A provider's charges for comparable services provided to non-recipients other than persons eligible for payment on a reduced or sliding fee schedule.
(a) Eligible providers. A mental health clinic which is certified, has a provider agreement and a contract is eligible to participate as a provider.
(b) Enrollment as provider. A facility which wishes to participate in the Medicaid program shall apply on the forms specified by the Department. The Department shall review the forms within ten working days after the date it receives the forms and all necessary information. If the application is not approved, the Department shall, in writing, specify the reasons for the decision and advise the applicant of its right to reapply.
(c) Termination of provider agreement.
(i) A provider which loses its certification shall be terminated as provider effective the same date the provider loses certification; or
(ii) A provider may be terminated pursuant to the provider agreement, the contract or the rules of the Department.
(d) Request for administrative hearing. A provider which is terminated as a Medicaid provider may request an administrative hearing regarding the termination pursuant to Chapter I. The filing of a request for an administrative hearing shall not stay the effective date of the termination.
(a) Covered services. Mental health clinic services provided;
(i) At a mental health clinic to an outpatient;
(ii) By or under the supervision of an affiliated physician;
(iii) As treatment for a recipient with a primary diagnosis of a mental disorder on Axis I,
Axis II, or both, as set forth in the DSM; and
(iv) Pursuant to a treatment plan, updated and signed by the affiliated physician at least every ninety days if treatment is continuing.
(b) Mental health rehabilitative services. The following limitations apply to rehabilitative services:
(i) Eligible providers. Providers of mental health rehabilitative services must also be providers of mental health clinic services and must meet the requirements of this rule relating to mental health clinic services except:
(A) The affiliated physician is not required to certify the medical necessity of treatment plans developed by a mental health professional other than the initial treatment plan;
(B) A written re-referral by a physician is required every twelve months if mental health rehabilitative services continue to be medically necessary;
(C) The affiliated physician may waive the requirement to see a recipient in person within the first forty-five days. Such a waiver must be in writing, signed by the physician and included in the clinical record;
(D) Mental health rehabilitative services are services provided pursuant to a treatment plan that are in lieu of, and not incidental to, mental health clinic services of individual and family/couples therapy; and
(E) The medical record of a recipient receiving mental health rehabilitative services must document recipient eligibility, include an assessment of emotional, behavioral, social functioning and environmental factors which substantiate the need for such services. Such assessment must be completed within thirty days after the first therapeutic face-to-face contact with the recipient.
(ii) Eligible recipients. The following recipients are eligible for mental health rehabilitative services:
(A) Recipients age 19 or over who are chronically mentally ill or who have a persistent and severe mental disorder in conjunction with at least a one-year history of significant deficits in social functioning related to the disorder;
(B) Recipients under age 19 who have a severe and persistent mental disorder or are at risk for developing such a disorder because of severe environmental stressors; or
(C) Recipients who have a serious mental disorder but who, because of age, physical incapacity, cultural barriers or other compelling circumstances require involvement of specialized family and/or community resources if mental health rehabilitation is to succeed.
(c) Excluded services.
(i) Broken or missed appointments;
(ii) Consultation and education;
(iii) Day care;
(iv) Driving while under the influence (DWUI)
classes;
(v) Emergency services delivered outside the provider’s facility (except for recipients receiving mental health rehabilitative services) or not provided through face-to-face contact with the recipient;
(vi) Group mental health rehabilitative services; (vii) Hospital liaison;
(viii) occupational therapy;
(ix) mental health rehabilitative services provided to a recipient with a sole diagnosis of substance abuse or dependency;
(x) Psychological testing done for the purpose of educational diagnosis, school or institution admission or placement;
(xi) Recreation and socialization services;
(xii) Remedial education;
(xiii) Reports made to other individuals or entities on behalf of a recipient;
(xiv) Residential care;
(xv) Services provide
(A) DSM diagnosis on Axis III;
(B) DSM diagnosis of mental retardation;
(C) DSM diagnosis of factitious disorder;
(D) DSM Axis I diagnosis of any v code unless the recipient’s medical record contains a written statement signed by the affiliated physician explaining why the treatment of a condition that is not a mental disorder is medically necessary;
(E) DSM diagnosis of 799.90 on Axis I or Axis II; or (F) DSM diagnosis of specific developmental disorders.
(xvi) substance abuse prevention services;
(xvii) support groups such as AA or NA;
(xviii) Time spent:
(A) Preparing records or reports;
(B) Consulting with non-recipients on behalf of a recipient unless the consultation
is part of a face-to-face contact with a recipient or a face-to-face contact with a collateral on behalf of a client receiving mental health rehabilitative services; (C) In telephone conversations; and
(D) Travelling.
(xix) Vocational services.
Section 6. Verification of recipient data.
(a) Medicaid Identification Cards. The Department issues Medicaid identification cards to recipients. Such cards are valid only for the month and year shown on the card.
(b) Services provided to a recipient who does not possess a valid Medicaid identification card are not Medicaid reimbursable.
A client without a valid medicaid identification card who seeks services is responsible for all charges for such services unless the provider receives written verification of eligibility from the Department or local agency before providing services.
Section 7. Out of state services.
Services provided by a mental health clinic located outside Wyoming are not Medicaid reimbursable.
Section 8. Quality assurance.
(a) Quality assurance plan. Each provider shall develop a quality assurance plan that meets DCP requirements for:
(i) Admission, discharge and length of stay criteria for each service for which the provider receives Medicaid reimbursement;
(ii) Standards and format for clinical records, including criteria for chart completeness review;
(iii) Definitions of critical incidents which require professional review and review procedures; and (iv) Criteria and procedures for peer review.
(b) Quality assurance committee. Each provider shall establish a quality assurance committee. The committee shall consist of clinical staff and shall include non-supervisory clinical staff. The committee shall:
(i) Review, at least semi-annually, at least ten percent of all open Medicaid cases. The cases reviewed shall include cases of each clinical staff member and a proportionate number of mental health clinic cases and substance abuse cases if the provider provides both types of services;
(ii) Document the results of the review;
(iii) Document in the medical records of each reviewed recipient the types of reviews, the date of such reviews and the name of the reviewer;
(iv) Ensure that no clinician reviews a case in which that clinician is the primary or co-therapist;
(v) Keep written records of all committee activities; and
(vi) Prepare a written report at twelve month intervals that synthesizes the findings of the review and contains recommendations to management for the improvement of services and correction of deficiencies.
(a) Generally. Medicaid reimbursement shall be the lesser of the provider’s usual and customary charge and the state reimbursement rate.
(b) Annual unit costs.
(i) Each provider shall develop, using procedures certified by DCP, annual unit costs for individual mental health services and group mental health services. New providers shall submit with the initial application annual unit costs based on at least six months of financial data.
(ii) Annual unit costs shall be submitted to DCP, which shall consider them in determining the state reimbursement rate for the following year.
(a) Payer of last resort. Medicaid is the payer of last resort. A provider may not seek Medicaid payment for services provided to a recipient until payment from third parties has been sought pursuant to Chapter IV of these rules.
(b) Payment in full of covered services. If the service is a covered service under this Chapter, a provider may not request, receive or attempt to collect payment from the recipient for the service. The provider must accept the amount paid by Medicaid as payment in full for the services.
(c) Payment for noncovered services. A provider who provides a noncovered service to a recipient may seek payment from the recipient if the provider informed the recipient of the recipient's potential liability before providing the service, and the recipient agreed in writing to pay for such services before they were provided.
(d) Submission of claims.
(i) Claims must be submitted to the Department in the manner and on the forms specified by the Department, must include documentation of prior authorization, and such other documentation or records as the Department may request.
(ii) Claims must be submitted to the Department on or before twelve months after the date of service, except that Medicare cross-over claims must be submitted within six months after the date Medicare acts on the claim. The date of submission is the date the claim is received by the Department. Claims not timely submitted shall be rejected.
(iii) A provider shall not bill the Department in excess of the provider's usual and customary charge for the service.
(iv) A provider may seek Medicaid payment through a business agent for services provided to a recipient if: the business agent's compensation is related to the actual cost of processing the billing and is not related on a percentage or other basis to the amount of the claim and is not dependent upon payment of the claim.
(a) Notice of excess payments. After determining that a provider has received excess payments, the Department shall send written notice to the provider stating the amount of the excess payments, the basis for the determination of excess payments and the provider's right to request reconsideration of that determination pursuant to Section 12.
(b) Reimbursement of excess payments. A provider must reimburse the Department for excess payments within 30 days after the provider receives written notice from the Department of the excess payments, even if the provider has requested reconsideration of or appealed the determination of excess payments, unless the provider has agreed in writing with the Department that such payments may be recovered by the withholding of all or part of future Medicaid payments.
(c) Methods of recovery of excess payments. If a provider does not timely reimburse the Department, the Department may recover the excess payments by:
(i) Withholding all or part of Medicaid payments until the excess payments are recovered, even if the provider has requested reconsideration of or appealed the determination of excess payments;
(ii) Initiating a civil lawsuit against the provider; or
(iii) Any other method of collecting a debt or obligation permitted by law.
(a) Request for reconsideration. A provider may request that the Department reconsider a decision to recover excess payments.
Such request must be mailed to the Department by certified mail within twenty days after the date the facility receives notice pursuant to Section 11. The request must state with specificity the reasons for the request. Failure to provide such a statement shall result in the dismissal of the request with prejudice.
(b) Reconsideration. The Department shall review the decision and send written notice to the provider of its final decision within forty-five days after receipt of the request for reconsideration. The Department may request additional information from the provider as part of the reconsideration process.
(c) Administrative hearing. A provider may request an administrative hearing regarding the final decision pursuant to Chapter I of these rules by mailing by certified mail or personally delivering a request for hearing to the Department within twenty days of the date the provider receives notice of the final decision. The request for hearing must comply with the requirements of Chapter I.
(d) Failure to request reconsideration. A provider which fails to request reconsideration pursuant to this section may not subsequently request an administrative hearing pursuant to Chapter I regarding the decision to recover excess payments.
(a) Retention. A provider shall maintain medical and financial records, including information regarding dates of services, diagnoses, services provided, and bills for services, for at least six years after the end of the federal fiscal year (September 30) in which the services were rendered. If an audit is in progress, the records must be maintained until the audit is resolved. Such records must be maintained for three years in hard-copy, after which they may be maintained on micro-fiche or icro-film.
(b) Availability of records. A provider shall maze financial or medical records available upon request to representatives of the Department, the United States Department of Health and Human Services, HCFA, the Wyoming Attorney General or the Wyoming Auditor.
(c) Refusal to produce or maintain records. The refusal of a provider to make financial or medical records available and accessible shall result if the immediate suspension of all Medicaid payments to the provider and all Medicaid payments made to the provider during the record retention period for which records supporting such payments are not produced shall be repaid to the Department within ten days after written request for such repayment, and the Department shall suspend all Medicaid payments for services provided after such date. Reimbursement shall not be reinstated until the Department determines that adequate records are being maintained.