Wyo. Code R. 048-0037-1
Medicaid
Effective Date: 07/01/1992 to 02/18/1997
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.1.07011992
health/medicaid/01_Medicaid_Administrative_Hearings Agency HEALTH Health, Dept. of Program MEDICAID Medicaid Chapter Name Medicaid Administrative Hearings
Chapter No.1
Date Filed 07/01/92 Expr Date
Supr Date
Document Type RULES
Section 1. Authority. These rules are 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.
Section 2. Purpose. These rules have been adopted to provide uniform procedures for the conduct of contested cases involving Medicaid issues.
Section 3. Applicability. All contested cases involving Medicaid shall be conducted in accordance with these rules, except hearings involving the denial, suspension or termination of eligibility, which shall be held pursuant to the rules and procedures of DFS, and except as otherwise specified in the Department's rules.
(a) 'Adverse Action.' The termination, suspension, reduction or denial of eligibility or covered services, including a reduction in the level of care of a nursing facility resident; the termination, suspension or other sanction of a provider; the denial of certification; the determination of a per diem rate pursuant to Chapter VII; and the denial or reduction of Medicaid payment to a provider, other than a reduction from the billed charges to the Medicaid allowable payment. 'Adverse action' does not include: (i) an appeal of a rate setting methodology; or (ii) an appeal from the termination, suspension, reduction or denial of eligibility, covered services, Medicaid payment to a provider or any other action caused solely by a change in Federal or state statutes or regulations.
(b) 'Affidavit.' A written notarized statement of facts made voluntarily under oath.
(c) 'Appeal.' A contestant's resort to district court after a final decision.
(d) 'Applicant.' A person whose written application for Medicaid has been submitted to the Department of Family Services or the Social Security Administration, but has not received final action.
(e) 'Claim.' A request by a provider for Medicaid payment for covered services provided to a recipient.
(f) 'Contestant.' The person who requests a hearing.
(g) 'Contested case.' A proceeding under these rules involving an adverse action.
(h) 'Covered services.' A service eligible for Medicaid funds under W. S. 42-4-103 or the rules of the Department.
(i) 'Denial of certification.' A decision by the medical review agent, after a request for reconsideration pursuant to the rules of the Department, which results in the denial or partial denial of admission certification for inpatient hospital services.
(j) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(k) 'DFS.' The Wyoming Department of Family Services, its agent, designee or successor.
(l) 'Director.' The director of the Department or his designee.
(m) 'Effective date.' The date on which an adverse action is to become effective, or the date of correspondence or other notice from the Department, including a remittance advice, communicating an adverse action for which there is no specified future effective date.
(n) 'Ex parte matter.' Matters which may be heard by the hearing officer in the absence of and without notice to the adverse party.
(o) 'Final decision.' The Department's final decision after a contested case.
(p) 'Fraud.' An intentional act of deception or misrepresentation, including any act that constitutes fraud under applicable Federal or State statutes or rules and regulations.
(q) 'Hearing.' A contested case hearing before a hearing officer.
(r) 'Hearing officer.' The individual designated by the Director to serve as the presiding officer at a hearing held under these rules.
(s) 'Indispensable party.' Any person whose joinder as a party is so important to a just resolution of the contested case that if he cannot be joined the action should not be allowed to proceed. The hearing officer will determine who is an 'indispensable party.'
(t) 'Inpatient hospital services.' Services provided by or under the supervision of a physician after a recipient's admission to a hospital as an inpatient. The inpatient hospital service may be furnished by the hospital, a physician, or a provider of an ancillary service.
(u) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act, as amended, and the Wyoming Medical Assistance and Services Act, as amended.
(v) 'Medicaid allowable payment.' The amount of Medicaid funds the Department will pay a provider for a particular service rendered to a recipient, as determined pursuant to the applicable rate setting methodology.
(w) 'Medical review agent.' The representative of the Department authorized by the Department to make decisions about the certification of inpatient hospital services.
(x) 'Notice' or 'notify.' A written notice mailed by or hand delivered in which the Department or its agent communicates the adverse action. 'Notice' includes a remittance advice. Except as otherwise provided by these rules, notice of adverse action shall include a statement of the reasons for and the evidence supporting the adverse action, the effective date of the adverse action, the right to a hearing, and, if applicable, an explanation of the circumstances under which benefits may be continued pending a hearing.
(y) 'Person.' An applicant, a recipient or a provider.
(z) 'Provider.' A vendor of covered services that has a provider agreement with the Department.
(aa) 'Provider agreement.' A written agreement between a provider and the Department.
(bb) 'Recipient.' A person who has been determined eligible for Medicaid.
(cc) 'Remittance advice.' A written statement mailed to a provider by the Department or its agent advising the provider of the disposition of a claim.
(dd) 'Request for hearing.' A written request for a hearing that includes the name, address, and telephone number of the person requesting the hearing, the reason for the request, and the adverse action being contested.
(ee) 'Respondent.' The Department.
(a) Applicants. An applicant has a right to a hearing pursuant to the rules and procedures of DFS if the application is denied or not acted upon within a reasonable time.
(b) Recipients. A recipient has a right to a hearing pursuant to the rules and procedures of DFS if Medicaid services are terminated or suspended. A recipient has a right to a hearing pursuant to this rule if services are reduced.
(c) Providers. A provider has a right to a hearing regarding an adverse action.
(a) Applicants and recipients. DFS shall notify applicants and recipients of the right to a hearing at the time of application and at the time of any adverse action other than a reduction in services, in which case the Department shall provide such notice. The notice shall include a statement of:
(i) The right to a hearing;
(ii) The method of requesting a hearing; and
(iii) That the applicant or recipient has the right to be represented by a lawyer, a relative, a friend or other spokesperson.
(b) Providers. The Department shall notify a provider of the right to a hearing at the time of the notice of adverse action, except when issuing a remittance advice. A provider shall be notified of the right to a hearing involving claims at the time the provider executes a provider agreement.
(a) Applicants and recipients. Notice of adverse action shall be in writing and shall include:
(i) A statement of the intended action;
(ii) The effective date of the intended action;
(iii) The reasons for the intended action;
(iv) The specific regulations that support, or the change in Federal or State law that requires the action;
(v) An explanation of:
(A) The individual's right to request a hearing; or
(B) In cases of action based on a change in law, the circumstances under which a hearing will be granted; and
(vi) An explanation of the circumstances under which benefits may be continued if a hearing is requested.
(b) Providers. Except as otherwise specified in this rule, notice of adverse action shall be in writing and shall include:
(i) A statement of the intended action;
(ii) The reasons for the intended action; and
(iii) The provider's right to request a hearing.
(a) Applicants and recipients. Except as otherwise specified in this rule, the Department shall mail notice of adverse action at least 10 days before the effective date.
(i) The Department may shorten the period of advance notice to five (5) days before the effective date if:
(A) The Department has facts indicating that action should be taken because of probable fraud by the recipient; and
(B) The facts have been verified, if possible, through secondary sources.
(ii) The department may mail notice not later than the effective date if:
(A) The Department has factual information confirming the death of a recipient;
(B) The Department receives a clear written statement signed by a recipient that:
(I) The recipient no longer wishes services;
(II) Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information; or
(III) The recipient has been admitted to an institution where he is ineligible under the plan for further services.
(C) The recipient's whereabouts are unknown and the post office returns agency mail indicating no forwarding address;
(D) The Department establishes that the recipient has been accepted for benefits by another local jurisdiction, State, territory or commonwealth; or
(E) A change in the level of medical care is prescribed by the recipient's physician.
(b) Providers.
(i) Notice of denial or reduction of payments. The Department shall notify a provider of the denial or reduction of payments as soon as practicable after such denial or reduction.
(ii) Notice of termination, suspension or sanction. The Department shall notify a provider of the termination, suspension or other sanction on or before the effective date.
(a) Applicants and recipients. A request for a hearing shall be mailed or personally delivered to the Department within thirty (30) days after the date the notice of adverse action is mailed to the applicant or recipient.
(b) Providers. A request for a hearing shall be mailed by certified mail or personally delivered to the Department within twenty (20) days after the date the notice of adverse action is received by the provider.
(a) The Department shall evaluate the request and, within twenty (20) days of receipt of the request:
(i) Notify the requesting party that a determination in his or her favor has been made and specify the action to be taken by the Department;
(ii) Give notice to the requesting party that a hearing will be held, the time, date and place of the hearing; or
(iii) Notify the requesting party of the denial of a hearing as requested and the reasons for the denial. A hearing may be denied if the request for a hearing does not meet the definition of a contested case. A denial of a request for a hearing is a final decision of the Department which may be appealed to the district court pursuant to the Wyoming Administrative Procedure Act.
(a) If the Department mails the 10-day or 5-day notice as required above, and the recipient requests a hearing before the effective date, the Department may not terminate or reduce services until the final decision is rendered after the hearing unless:
(i) It is determined at the hearing that the sole issue is one of Federal or State law or policy; and (ii) The Department promptly informs the recipient in writing that services are to be terminated or reduced pending the final decision.
(b) If the adverse action is affirmed, the Department may institute recovery procedures against the applicant or recipient to recoup the cost of any services furnished to the recipient, to the extent they were furnished solely by reason of this section, or recover any excess payments made to a provider.
(a) In any contested case, the Director shall afford reasonable notice of the hearing to all parties.
(i) Reasonable notice, as used in this section, shall be not less than 20 days prior to the hearing date. The time period may be waived by the contestant upon written or oral notification to the Department. Where notification of waiver is made orally it shall be reduced to writing by the Department and entered in the contestant's record.
(ii) Notice shall be served personally or by certified mail to the last known address of the party.
(iii) Where the necessary and indispensable parties are composed of a large class, notice shall be:
(A) Served upon a reasonable number of representatives of the class; or
(B) Published in newspaper(s) of the State in reasonable numbers and times, and at a minimum in a paper of general circulation in the county in which the contestant resides, and in at least one newspaper with state-wide circulation. In any county in which more than one newspaper is published, notice shall be published in the official paper of the county designated pursuant to W.S. 18-3-517.
(b) A notice of hearing shall contain the time, place, and nature of the hearing; the legal authority and jurisdiction under which the hearing is being held; the particular sections of the statutes or rules involved; a short and plain statement of the matters asserted; the docket number assigned to the case; the right to be represented by an attorney; availability of legal aid; and the right to a hearing.
(i) If the Respondent is unable to state the matters in detail at the time notice is served, the initial notice may be limited to a statement of the issues involved, and thereafter, upon request of any party, a more definite and detailed statement shall be furnished within ten (10) days of receipt of that request by the party.
(ii) Upon written request by the contestant, or upon his own motion, the hearing officer may reschedule the hearing to a time convenient for the parties. The contestant must submit such a request within ten (10) days of receipt of the notice of hearing. When such request is granted, the Director shall reissue the notice in accordance with these rules except that reasonable notice as used in this subsection shall be five (5) days prior to the hearing date.
(A) Only one request for rescheduling of a hearing shall be honored unless, in the hearing officer's judgment, additional changes must be allowed to avoid manifest injustice. Notice shall be issued as provided by subsection (ii).
(B) A hearing shall be held within ninety (90) days of the action which gives rise to the request for a hearing, unless otherwise provided by law or by agreement of the parties.
Section 13. Procedural rights of contestant. The contestant, or his representative, must be given the opportunity to:
(a) Examine, at a reasonable time before the date of the hearing and during the hearing:
(i) The content of the contestant's case file; and
(ii) All documents and records to be used by the Department at the hearing.
(b) Bring witnesses, establish all pertinent facts and circumstances, present an argument, and question or refute any testimony or evidence, including opportunity to confront and cross-examine adverse witnesses.
Section 14. Failure to Appear. If a contestant fails to appear at the place, date, and time specified in a notice, the hearing officer may:
(a) Continue the hearing to a later date and provide proper notice as prescribed in these rules; or
(b) Proceed to conduct the hearing without the contestant and dispose of the contested case, unless prohibited by Federal or State statute; or
(c) Deny or dismiss a hearing if:
(i) The contestant withdraws the request in writing; or
(ii) The contestant fails to appear at a scheduled hearing without good cause.
(A) Good cause shall be determined by considering circumstances which are beyond the contestant's control, such as illness, illness of another household member requiring the presence of the contestant, a household emergency, unavailability of transportation, lack of adequate child care or other such circumstances which the hearing officer determines were beyond the contestant's control.
All discovery in a contested case shall be governed by the Wyoming Rules of Civil Procedure, as described in w. s. 16-3-107(g) and (h). The party for whom any depositions are taken will ensure that the original transcripts are placed in the record by filing them with the Director. All other records of discovery shall likewise be filed with the Director or his designee by the party originating such discovery.
(a) At a time on or before the day of the hearing, the hearing officer, on his own or either party's motion, may meet with the parties for a conference to consider simplification of the issues, stipulations and admissions of fact, clarification or limitation of evidence, and any other matters that may expedite the proceeding and assure a just conclusion of the case.
(b) Any stipulations, limitations or agreements made at a prehearing conference shall be recited in the record and shall control the course of the proceedings, unless modified during the hearing to prevent manifest injustice.
(a) Settlement of a contested case by any informal means (i.e. stipulation, agreed settlement or consent order) shall be allowed at any time, unless precluded by law. Such settlements shall be in writing, signed by both parties and included as a part of the record. The Director shall enter an order dismissing the contested case proceeding upon such settlement, and such order shall be considered a final order of the Department.
(b) Settlement conference. Any party may request that the matter be set for a settlement conference. Upon such request, the hearing officer shall schedule a conference and direct that a representative of each party attend, such representative to have authority to settle the matter. The hearing officer shall neither attend the conference nor be advised of the proposals of either party. The hearing officer may designate another individual, not previously involved in the matter, to attend the conference and assist the parties in attempting to reach a settlement.
(a) The Director shall appoint a hearing officer to preside over contested case hearings on a case-by-case basis, or for a scheduled period of time, as he sees fit.
(b) The hearing officer shall be an employee of the Department, or other individual determined by the Director to be qualified to serve in such a capacity, who has not taken part in the investigation, preparation, or earlier disposition of the case to be heard.
(i) The hearing officer shall withdraw himself from consideration of a case at any time he deems himself disqualified providing there are other qualified presiding officers available to act. Withdrawal shall be made in writing to the Director.
(ii) Any party may request in writing that the Director remove and replace the hearing officer in a contested case. This request must be accompanied by a statement and affidavits, setting forth the alleged grounds for disqualification. The Director may deny a party's request for removal and shall issue a written statement explaining the grounds for his denial which shall be made a part of the record. If the request is granted, the Director shall appoint a new hearing officer as soon as is practicable.
(iii) The contestant may object to the appointment of the hearing officer in the record at the hearing. The objection shall set forth the alleged grounds for disqualification.
(c) The hearing officer shall have all powers necessary to conduct a fair and impartial hearing, including but not limited to, the following authority:
(i) To administer oaths and affirmations;
(ii) To subpoena witnesses and require the production of any books, papers or other documents relevant or material to the inquiry.
(iii) To rule upon offers of proof and relevant evidence;
(iv) To provide for discovery and determine its scope;
(v) To regulate the course of the hearing;
(vi) To hold conferences for the settlement or simplification of the issues;
(vii) To dispose of procedural requests or similar matters; and
(viii) To take any other action authorized by the Department's rules.
(d) Failure or refusal to appear or obey orders of the hearing officer may result in the sanctions provided in W.S. 16-3-107(c) and (f).
(e) Except to the extent required for the disposition of ex parte matters authorized by law, the hearing officer shall not consult with any individual or party on any fact at issue except as allowed in W.S. 16-3-111.
(a) Burden of proof. The contestant shall have the burden of proof.
(b) Admissibility of evidence.
(i) The parties shall be entitled to present any oral or documentary evidence, submit rebuttal evidence and conduct cross-examinations, as may be required for a full disclosure of the facts. All documentary or physical evidence submitted for consideration shall be marked as exhibits. Respondent's exhibits shall be marked by letters of the alphabet beginning with 'A.' Contestant's exhibits will be marked by numbers beginning with '1.'
(ii) The hearing officer shall allow any oral or documentary evidence, except irrelevant, immaterial or unduly repetitious evidence.
(c) Objections
(i) The grounds for objection to any evidentiary ruling by the hearing officer shall be briefly stated. Rulings on all objections shall appear in the record. Only those objections made before the hearing officer, or specifically stipulated to by both parties, may be relied on in a subsequent proceeding.
(ii) Formal exception to an adverse ruling is not required.
(d) Privileged and confidential information.
(i) Any privilege at law shall be recognized by the hearing officer in considering evidence.
(ii) No employee of the Department shall be compelled to testify or to divulge information which is confidential or privileged at law and which is contained within the records of the Department or acquired within the scope of his employment except as provided in W.S. 16-3-107.
(e) The hearing officer may take official notice of any material fact not appearing in evidence in the record that is of the nature of traditional matters of judicial notice or within the special technical knowledge or files of the Department. Parties shall be given an opportunity to contest matters officially noticed prior to a final decision by the Department in accordance with W.S. 16-3-108.
(f) Each witness who is present to give testimony must identify himself or herself by stating his or her name and address, indicate on whose behalf he or she will testify, and be administered the following oath by the hearing officer: 'Do you swear or affirm to tell the truth, the whole truth, and nothing but the truth?'
(a) All parties have a right to represent themselves, to be represented by an attorney authorized to practice pursuant to the rules of the Supreme Court of Wyoming, or, if the contestant is an applicant or recipient, any other person chosen by the contestant to appear on his behalf. If the contestant is represented by an attorney, payment of attorney's fees and cost are the responsibility of the contestant.
(i) Only a party, his attorney, or his representative may examine or cross-examine witnesses.
(ii) The hearing officer may examine witnesses.
(b) Respondent may request the Attorney General to assist in contested case hearings to the extent required by W.S. 16-3-112(c).
(a) As nearly as practicable, the following order of procedure shall be followed:
(i) The hearing officer shall announce the hearing is open and call by docket number and title the case to be heard. The hearing officer shall ask if parties are ready to proceed and will allow parties an opportunity to dispose of any preliminary matters.
(ii) The hearing officer shall administer the oath to all witnesses who will present testimony.
(iii) The hearing officer may, in his discretion, allow evidence to be heard in an order other than that prescribed here.
(iv) Opening statements may be made, contestant first, then Respondent.
(v) Evidence will be heard, contestant first, then Respondent. Contestant may then offer rebuttal evidence. Parties may cross-examine.
(vi) No testimony shall be received by the Hearing Officer unless given under oath/affirmation administered by the Hearing Officer.
(vii) Closing statements may be made, contestant first, then Respondent, then the contestant in rebuttal.
(viii) The hearing officer may limit the time for opening and closing statements.
(ix) After all parties have had an opportunity to be heard, the hearing officer shall excuse all witnesses and close the evidence.
(x) Evidence may be reopened only upon a motion by a party to the proceeding on a showing of good cause.
(b) Upon their own motion, all parties or other interested persons may submit legal briefs after the close of the hearing. The hearing officer shall allow a reasonable time, not less than ten (10) workings days from the date of hearing, for preparation of the briefs. The time may be extended upon agreement between the parties with the approval of the hearing officer.
(a) The hearing officer shall make proposed findings of fact and conclusions of law within (20) working days of the close of the hearing and forward them to the Director for final determination. This time may be extended if the parties or other interested persons are to submit briefs; but may not be extended by more than ten (10) working days, unless the parties stipulate, in writing, to a later date.
(i) Within ten (10) working days of the close of the hearing, or such additional time as the hearing officer may allow, each party shall be allowed to file with the hearing officer any proposed findings of fact and conclusions of law, together with a supporting brief. Such proposals and briefs shall be served on all other parties.
(b) Within ten (10) working days of receipt of the hearing officer's proposed findings of fact and conclusions of law, the Director shall make and enter into the record the final decision. The final decision shall be served on all parties to the proceedings. The final decision shall include:
(i) A statement of the findings of fact and conclusions of law; and
(ii) The appropriate rule, order, relief or denial thereof. The decision shall be based upon the contested case record or any portion stipulated to by the parties. The decision shall include facts officially noticed and relief upon as provided by W.S. 16-3-108(d). It shall be made on the basis of a preponderance of evidence contained in the record.
(c) Final decisions of the Department shall be effective immediately after being entered in the record and served upon all parties. Service shall be personal or by mailing a copy of any decision or order to each party or the party's attorney of record within a reasonable time after the entry of the decision into the record.
Appeals from a final decision of the Department shall be in accordance with W.S. 16-3-114 and Rule 12 of the Wyoming Rules of Appellate Procedure.
(a) When a contested case is set for hearing, the Director shall assign a docket number to each case and enter the case with its number and date of filing on a docket. The Director shall maintain a separate file for each docketed case in which all pleadings, transcriptions, correspondence, papers, and exhibits for that case shall be maintained. All such items shall have noted thereon the assigned docket number and the date of filing.
(b) The Department shall record all contested case proceedings electronically, through the use of a qualified court reporter or any other appropriate means determined by the agency, or the hearing officer. Transcriptions of oral proceedings or written transcripts of a witness's testimony may be obtained by contestant upon payment of the cost.
(i) In a nonpublic investigatory proceeding, requests for copies or transcripts may be limited to testimony of the requesting party.
(ii) Where contestant can demonstrate that he is indigent and that he cannot effectively perfect his appeal without such transcription the Department may waive the payment of the fee.
(c) The record of the hearing shall contain:
(i) All formal or informal notices, pleadings, motions and intermediate rulings;
(ii) Evidence received or considered, including matters officially noticed;
(iii) Questions and offers of proof, objections and rulings;
(iv) Any proposed findings and exceptions thereof; and
(v) The report of the hearing officer and the final decision.
Section 25. Severability.
If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.
The Wyoming Department of Health (the Department) is the single state agency appointed pursuant to the Social Security Act (the Act) to administer the Medicaid program in Wyoming. The Wyoming Medical Assistance and Services Act of 1967 (the Wyoming Act) requires the Department to administer the Medicaid program in conformance with federal standards.
The Wyoming Act authorizes the Department to promulgate necessary rules. The Wyoming Administrative Procedure Act requires all agency statements of general applicability that implement, interpret or prescribe law or policy be promulgated as rules.
The Health Care Financing Administration of the United States Department of Health and Human Services HCFA) is the federal agency for administering the Medicaid program. HCFA regulations, the decision of the United States Supreme Court in Goldberg v. Kelly, and the Wyoming Administrative Procedure Act require the Department to provide a fair hearing process for persons who are denied Medicaid and recipients of Medicaid benefits if there is a reduction or termination of services. HCFA regulations also require the Department to provide a fair hearing process for providers of Medicaid services whose participation in Medicaid is terminated or sanctioned, or whose requests for Medicaid reimbursement are reduced or denied.
This rule is being promulgated to amend Chapter I to clarify the scope of an adverse action. It is being promulgated to replace the existing Chapter I, which was promulgated as an emergency rule.