Wyo. Code R. 048-0037-22
Medicaid
Chapter 22: Nursing Facility Evaluation of Medical Necessity
Effective Date: 08/01/1995 to 11/18/1997
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.22.08011995
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.
(a) This rule establishes methods and standards for evaluations of medical necessity for applicants and recipients seeking nursing facility services. The requirements of this Chapter apply to all applicants and recipients.
(b) The Department may issue Provider Manuals, Provider Bulletins, or both, to interpret the provisions of this Chapter. Such Provider Manuals and Provider Bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in Provider Manuals or Provider Bulletins shall be subordinate to the provisions of this Chapter.
(a) This rule is intended to be read in conjunction with Chapter 19 of these rules.
(b) Terminology. 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.
(a) 'Admission.' The act that allows an individual to officially enter a facility to receive nursing facility services.
(b) 'Applicant.' A person, including a patient, who has applied for Medicaid benefits and is a resident or is seeking admission to a facility.
(c) 'Appropriate placement.' The placement of an individual in a treatment setting when the individual's needs meet the minimum standards for admission to that treatment setting and the individual's needs for treatment do not exceed the level of services which the treatment setting is capable of providing.
(d) 'Chapter 1.' Chapter 1, Medicaid Fair Hearings, of the Wyoming Medicaid Rules.
(e) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(f) 'Chapter 9.' Chapter 9, Hospital Services, of the Wyoming Medicaid Rules.
(g) 'Chapter 19.' Chapter 19, Nursing Facility Preadmission Screening, of the Wyoming Medicaid Rules.
(h) 'Date of admission.' The date an individual enters a facility and begins receiving nursing facility services.
(i) 'Date of referral.' The date the medical necessity evaluator receives a referral.
(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) 'Discharge.' The act by which an individual who has been a patient in a facility ceases to be a patient and the facility ceases to be legally responsible for providing care for such individual. 'Discharge' does not include an individual's temporary absence from the facility for treatment in a hospital, home visits or a trial community stay provided such temporary absence is not longer than thirty consecutive days.
(m) 'Division.' The Health Care Financing Division of the Department, its agent, designee or successor.
(n) 'Excess payments.' Medicaid funds received by a provider to which the provider is not entitled, including Medicaid funds received for services furnished to a recipient in the absence of a timely determination of medical eligibility pursuant to Sections 5 and 6.
(o) 'Evaluation of medical necessity.' A review, pursuant to Section 5, by a medical necessity evaluator of an applicant's or recipient's physical and mental condition for the purpose of determining whether the individual requires nursing facility level of care.
(p) 'Facility.' A skilled nursing facility (SNF) or a nursing facility that meets all of the requirements of state licensure and certification for participation in the Medicaid program. 'Facility' may include a distinct part of a hospital or institution which is designated to provide nursing facility services.
(q) 'HCFA.' The Health Care Financing Administration of the United States Department of Health and Human Services.
(r) 'Home or community-based waiver services (HCBS).' Services provided under a waiver from HCFA that are not otherwise available under the Wyoming Medicaid state plan. Such services enable the elderly, disabled, and chronically mentally ill persons, who would otherwise be placed in an institution, to live in the community. Section 1915(c) of the Social Security Act specifies the services that may be included as HCBS waiver services. 'HCBS waiver services' includes home and community-based services as specified in each applicable waiver.
(s) 'Hospital.' A hospital as defined in Chapter 9, which definition is incorporated by this reference.
(t) 'Long Term Care Review Document (LT 101).' The Title XIX Long Term Care Review Document as prepared by the Department.
(u) 'Long Term Care HCBS Waiver.' An HCBS waiver that provides in-home services to recipients nineteen years of age or older that require services equivalent to a nursing facility level of care.
(v) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(w) 'Medically necessary.' Nursing facility services are required because of an individual's functional ability as determined by an evaluation of medical necessity pursuant to this Chapter.
(x) 'Medical necessity evaluator.' A public health nurse or registered nurse that is under contract to the Department to function as the medical necessity evaluator, or, in areas where no contract exists, designated staff of the Department acting in concert with local medical professionals.
(y) 'Nursing facility.' A nursing facility as defined by 42 U.S.C. § 1396r(a), which is incorporated by this reference.
(z) 'Nursing facility services.' 'Nursing facility services: as defined in 42 U.S.C. § 1396d(f), which is incorporated by this reference.
(aa) 'PASARR.' Preadmission screening and annual resident review conducted pursuant to Chapter 19.
(bb) 'Patient.' A resident of a facility.
(cc) 'Physician.' A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a comparable agency in another state.
(dd) 'Provider.' 'Provider' as defined by Chapter 3, which definition is incorporated by this reference.
(ee) 'Provider agreement.' 'Provider agreement' as defined by Chapter 3, which definition is incorporated by this reference.
(ff) 'Public health nurse.' A registered nurse who is either under contract to the County to perform public health nursing functions or is an employee of the Department that is assigned public health nursing functions.
(gg) 'Recipient.' An individual that has been determined eligible for Medicaid.
(hh) 'Referral.' A communication, written or oral, to the medical necessity evaluator indicating that an individual seeking admission to or on the premises of a nursing facility requires an evaluation of medical necessity.
(ii) 'Registered nurse.' A person licensed to practice professional nursing by the Wyoming State Board of Nursing or a comparable agency in another state.
(jj) 'Swing bed.' A bed in a hospital which is certified for either inpatient hospital service or nursing facility services.
(kk) 'Working day.' 8:00 a.m. through 5:00 p.m., Mountain Time, Monday through Friday, exclusive of state holidays.
(a) Purpose. To determine whether an applicant or recipient requires nursing facility services or HCBS waiver services equivalent to a nursing facility level of care.
(b) Applicability.
(i) All nursing facility, swing bed and Long Term Care HCBS Waiver applicants or recipients must undergo an evaluation of medical necessity before a provider may receive Medicaid reimbursement for services provided to that individual.
(ii) Any nursing facility or swing bed applicant or resident, regardless of payment source, who is referred for a PASARR Level II evaluation must undergo an evaluation of medical necessity as part of the determination of appropriateness of nursing facility placement.
(c) Criteria. The medical necessity evaluator shall determine whether nursing facility services are necessary by evaluating individuals according to criteria specified by the Division.
(d) Recipients admitted to a facility before April 1, 1990 are exempt from the provisions of this Section unless the recipient:
(i) Seeks to transfer to another facility;
(ii) Is discharged and seeks readmission to the discharging facility or another facility; or
(iii) Loses Medicaid eligibility and subsequently reapplies for or seeks a redetermination of Medicaid eligibility.
(i) Any recipient seeking to transfer to another facility must be evaluated for medical necessity. Individuals receiving fewer than thirteen points shall lose nursing home eligibility upon transfer, but may retain nursing home eligibility by remaining in the facility.
(ii) The facility to which a recipient proposes to transfer shall not receive Medicaid reimbursement for services provided to the recipient unless the requirements of Section 5 are met.
(f) Readmissions. A recipient that is discharged and subsequently seeks readmission to a facility must be screened pursuant to this section, and the facility shall not receive Medicaid payment for services provided to the recipient if the recipient does not require a nursing facility level of care.
(i) A recipient who is discharged from a facility and readmitted within 30 days may be exempted from screening pursuant to this section.
(ii) A recipient who is discharged from a facility for longer than 30 days and seeks readmission is subject to screening under this section, except that an LT101 that is less than 45 days old at the time of the resident's readmission may be accepted as documentation of medical necessity.
(g) Redetermination of Medicaid eligibility. A recipient that loses Medicaid eligibility and subsequently seeks a redetermination of Medicaid eligibility must be screened pursuant to this Section, even if the individual has not been discharged. The facility in which the individual resides or into which admission is sought shall not receive Medicaid payment for services provided to the recipient if the level of care provided by that facility is not medically necessary.
(i) The nursing facility, hospital, DFS office or any representative of the individual to be evaluated may make a referral.
(ii) Evaluations of medical necessity shall be performed by the medical necessity evaluator by the end of the third working day after the referral.
(iii) The Department shall give written notice to the applicant or recipient within three days of the evaluation if the evaluation of medical necessity determines that the level of care offered by the facility is not medically necessary.
(i) Validity of evaluation of medical necessity.
(i) An evaluation of medical necessity pursuant to this section that results in thirteen points or more is valid for forty-five (45) days after the date of the evaluation.
(ii) If the evaluation of medical necessity is more than forty-five (45) days old at the time of admission, transfer or application for Medicaid eligibility, a new evaluation will be required.
(iii) If the evaluation of medical necessity is less than 45 days old at the time of application for Medicaid eligibility, it will be considered valid for eligibility determination purposes, regardless of the length of time the eligibility determination process takes.
(j) Re-evaluations. The medical necessity evaluator may choose to re-evaluate the individual if the individual's medical condition is expected to change. If more than one evaluation is performed, the points scored on the most recent evaluation will be the determining factor for medical necessity.
(k) Not a guarantee of eligibility. An evaluation of medical necessity that determines that nursing facility services are medically necessary is not a guarantee of the individual's eligibility for Medicaid nor of Medicaid reimbursement for services provided to the individual.
(a) Completion of evaluation of medical necessity. No facility shall receive Medicaid reimbursement for nursing facility services provided to a recipient until:
(i) The medical necessity evaluator has completed an evaluation of medical necessity which indicates that nursing facility services are medically necessary; and
(ii) The nursing facility has complied with Chapter 19.
(b) Retroactive payments. Retroactive payments are available pursuant to Chapter 19, which is hereby incorporated by reference.
Section 7. Recovery of excess payments. The Department may recover excess payments pursuant to the provisions of Chapter 3 and Chapter 16, which are incorporated by this reference.
(a) Request for reconsideration.
(i) A provider may request that the Department reconsider a decision to deny payment or to recover excess payments. A provider may not request that the Department reconsider a determination of medical necessity made pursuant to this Chapter. The request for reconsideration must be mailed to the Department by certified mail, return receipt requested within twenty days of the date the facility receives notice of the denial of payment or notice to recover excess payments. 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.
(ii) An applicant or recipient may request that the Department reconsider an adverse determination of medical necessity made pursuant to this Chapter. Such request must be mailed to the Department by certified mail, return receipt requested within twenty days of the date the individual receives notice of the finding of no medical necessity.
(b) Reconsideration. The Department shall review the decision and send written notice by certified mail, return receipt requested, to the party requesting reconsideration of its final decision within forty-five days after receipt of the request for reconsideration or the receipt of any additional information requested pursuant to (c), whichever is later.
(c) Request for additional information. The Department may request additional information from the provider or individual as part of the reconsideration process. Such a request shall be made in writing by certified mail, return receipt requested. The provider must provide the requested information within thirty days after the date of the request. Failure to provide the requested information shall result in the dismissal of the request with prejudice.
(d) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.
(e) Informal resolution. The Department or the party requesting reconsideration may request an informal meeting before the final decision on reconsideration to determine whether the matter may be resolved. The substance of the discussions and/or settlement offers made pursuant to an attempt at informal resolution shall not be admissible as part a subsequent administrative hearing or judicial proceeding.
(f) Failure to request reconsideration.
(i) A provider which fails to request reconsideration pursuant to this section of a decision to deny payment or to recover excess payments may not subsequently request an administrative hearing pursuant to Chapter I.
(ii) A recipient or applicant may elect not to request reconsideration and may request an administrative hearing pursuant to Chapter I. A recipient or applicant that requests reconsideration may request an administrative hearing at any time during reconsideration or within thirty days after the date the notice of final agency action is mailed. Such request for hearing shall be pursuant to Chapter I.
(a) Provider. Subject to subsection 8(f), a provider may request an administrative hearing regarding the final decision pursuant to Chapter I of these rules by mailing by certified mail, return receipt requested, or personally delivering a request for hearing to the Department within twenty days of the date the provider receives notice of the final decision.
(b) Applicant/recipient. An applicant or recipient may request an administrative hearing pursuant to Chapter I regarding the determination that nursing facility services are not appropriate or medically necessary. The request for an administrative hearing shall be made by mailing by certified mail or personally delivering a request for hearing to the Department within thirty days of the date of the notice of the adverse action.
Section 10. Superseding effect. 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 11. 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 Health Care Financing Administration of the United States Department of Health and Human Services (HCFA) is the federal agency responsible for administering the Medicaid program.
The Act and HCFA regulations proscribe the payment of Medicaid funds for services that are not medically necessary. Nursing facility services provided to an individual that does not require nursing facility services are not medically necessary, and result in the improper expenditure of Medicaid funds.
The Department promulgated Chapter XXII to establish the procedures and standards for evaluating the medical necessity of furnishing nursing facility services.
There have been significant changes in the procedures and standards used in evaluating the medical necessity of nursing facility services since the promulgation of the existing Chapter XXII. The rule is being amended to reflect and implement those changes. This amended rule will replace the existing Chapter XXII.