Wyo. Code R. 048-0037-31
Medicaid
Chapter 31: Selective Contracting of Services
Effective Date: 09/23/2019 to Current
Rule Type: Current Rules & Regulations
Reference Number: 048.0037.31.09232019
Section 1. Authority. This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at Wyoming Statutes §§ 42-4-101 through 42-4-412.
(a) This Chapter has been adopted to govern Medicaid reimbursement of specialty services, except as otherwise specified in the rules of the Department, and shall apply to all clients and providers for all specialty services provided on or after this Chapter's effective date.
(b) The Department may issue manuals and bulletins 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 and bulletins shall be subordinate to the provisions of this Chapter.
(a) Terminology. Except as otherwise specified in the Rules and Regulations of Wyoming Medicaid, Chapter 1, Definitions, or as otherwise specified in this Chapter, the terminology used in this Chapter is the standard terminology and has the standard meaning used in accounting, health care, Medicaid and Medicare.
(b) General methodology. The Department shall reimburse providers of specialty services pursuant to contracts with the providers. Except as otherwise specified by contract, selective services shall be provided pursuant to this Chapter.
(a) Payments only to providers. Except as otherwise specified in this Chapter, no provider that furnishes specialty services to a recipient shall receive Medicaid funds unless the provider is certified, has signed a provider agreement, is enrolled, and has signed a contract with the Department.
(b) Qualified provider. A provider or group of providers that contracts to provide specialty services must meet the criteria that the Department establishes as part of the selective contracting process.
(a) A provider shall comply with Chapter 3's provider records requirements.
(b) Out-of-state records. If a provider maintains financial or medical records in a state other than the state where the provider is located, the provider shall either transfer the records to an in-state location that is acceptable to the Department, or reimburse the Department for reasonable costs, including travel, lodging and meals, incurred in performing the audit in an out-of-state location, unless otherwise agreed by the Department.
Section 6. Verification of recipient data. A provider shall comply with Chapter 3's client data verification requirements.
(a) All-inclusive rate. No additional Medicaid reimbursement will be given to providers of specialty services. The only remuneration will be as specified in the all-inclusive contract rate.
(b) Services that require prior authorization or admission certification. The Department may require prior authorization or admission certification as a prerequisite to Medicaid payment. Failure to obtain prior authorization or admission certification shall result in the denial of Medicaid payment.
Section 8. Reimbursement of readmissions. Medicaid shall not reimburse for a readmission if the readmission is for continuation of treatment begun in the initial admission, and the Department determines that the treatment should have been provided during the initial admission.
(a) Medicaid reimbursement for specialty services furnished by non-contracting providers shall be limited to reimbursement for services provided in response to an emergency.
(b) The Medicaid reimbursement rate for specialty services furnished by a non-contracting provider to a recipient, in response to an emergency, shall be the average Medicaid rate paid to contracting providers for such services.
(c) Retroactive eligibility. Specialty services furnished by a non-contracting provider to an individual that becomes eligible for Medicaid after the date of admission, shall be reimbursed at the average Medicaid rate paid to a contracting provider for the same or similar services.
(a) Submission of claims. Claims for which third party liability exists shall be submitted in accordance with Chapter 35.
(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 11. Payment of Claims. Payment of claims shall be pursuant to Chapter 3, Provider Participation.
Section 12. Recovery of overpayments. The Department shall recover overpayments pursuant to Chapter 16, Medicaid Program Integrity.
Section 13. Reconsideration. A provider may request reconsideration of a request to recover overpayments pursuant to the provisions of Chapter 16, Medicaid Program Integrity.
(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 various provisions.
Section 15. Superseding effect. This Chapter supersedes all prior rules or policy statements issued by the Department, including manuals and bulletins, which are inconsistent with this Chapter.
Section 16. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in full force and effect.