Wyo. Code R. 048-0037-29
Medicaid
Chapter 29: Medicaid Case Management
Effective Date: 08/13/2020 to Current
Rule Type: Current Rules & Regulations
Reference Number: 048.0037.29.08132020
Section 1. Authority. The Department of Health (“Department”) promulgates this Chapter under Wyoming Statute 42-4-104.
Section 2. Purpose and applicability. This Chapter governs case management by establishing the responsibilities and powers of the Department, clients, providers, and facilities to address the most efficient and cost-effective means of delivering care.
(a) A hospital is not entitled to receive the full Medicaid allowable payment for covered services furnished to a client unless the hospital has reported the client to the Department on an Inpatient Census Report (“ICR”), subject to the following provisions:
(i) A hospital shall submit an ICR to the Department by 5:00 p.m. on Friday of each week.
(ii) An ICR must:
(A) Be submitted electronically in the form and manner established by the Department; and
(B) Report each client admitted to the hospital since the last ICR deadline.
(iii) If a hospital fails to timely report a client on an ICR, the hospital may not report the client on a subsequent ICR unless the client has not yet been discharged from the hospital.
(iv) If a hospital makes a late report of a client on an ICR, the Department may reduce, by up to twenty-five percent (25%), the Medicaid allowable payment to the hospital for all covered services furnished to the client.
(v) If a hospital altogether fails to report a client on an ICR, the Department may reduce, by up to one hundred percent (100%), the Medicaid allowable payment to the hospital for all covered services furnished to the client.
(vi) If a hospital makes a late report of a client on an ICR late or altogether fails to report a client on an ICR and, nonetheless, the Department pays the hospital the full Medicaid allowable payment, the Department may recoup the overpayment pursuant to the procedures under Chapter 3 of Rules, Wyoming Department of Health, Medicaid (“the Medicaid Rules”).
(b) If a client is determined eligible for Medicaid only after discharge from the hospital, then the Medicaid allowable payment to the hospital shall not be reduced for failure to include that client on prior ICRs.
(a) The Department may subject a client to case management if the Department determines the client requires assistance in using covered services appropriately for any reason, including:
(i) The client appears unfamiliar with the Medicaid program or the delivery of services;
(ii) The client has a severe medical problem; or
(iii) The client is receiving high-cost services.
(b) If the Department subjects a client to case management, the Department need not notify the client.
(c) Case management includes the following actions:
(i) Monitoring the utilization of covered services to ensure that they are medically necessary and appropriate;
(ii) Conducting reviews of services while the client is at a facility;
(iii) Conducting on-site reviews with clients or providers to determine whether the provided services are medically necessary and appropriate; and
(iv) Taking any other action relevant to the coordination and facilitation of covered services in an efficient manner or setting consistent with the appropriate care for the client.
(a) The Department may lock-in a client if:
(i) The Department determines the client has engaged in fraud, theft, or abuse of services pursuant to Chapter 16 of the Medicaid Rules; or
(ii) The Department receives a referral from another Medicaid program which demonstrates that the client has previously engaged in fraud, theft, or abuse of services.
(iii) The client is receiving high-cost services.
(b) If the Department decides to lock-in a client pursuant to this Section, the
Department shall comply with the sanction procedures under Chapter 16, Section 10 of the Medicaid Rules.
(a) If a client requests a contested case proceeding regarding lock-in pursuant to Chapter 4 of the Medicaid Rules, the client lock-in remains in effect during the contested case proceeding unless the Department stays the lock-in according to the following provisions:
(i) In order for a stay of the lock-in to be granted, the client, client’s guardian, or an individual authorized to act on the client’s behalf, shall submit a written request for a stay to the Department concurrent with the request for a contested case proceeding. The request for a stay must include a statement regarding the potential impact on the client’s health and welfare if the lock-in were to remain in effect.
(ii) The Department may not grant a request for a stay unless the Department finds that the lock-in would cause the client irreparable harm.
(iii) If the Department grants a request for a stay, the Department may impose whatever conditions it finds necessary to protect the health and welfare of the client or the interests of the Medicaid program.
(iv) The Department shall provide written notice of its decision to grant or deny a request for a stay. The written notice must provide the grounds in support of the Department’s decision.