Wyo. Code R. 048-0037-31
Medicaid
Chapter 31: Selective Contracting of Hospital Serv.
Effective Date: 06/28/1994 to 02/18/1997
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.31.06281994
Date Filed 06/28/94
Expr Date
Supr Date
Repeal Date
Document Type RULES
This rule is 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 shall apply to and govern Medicaid reimbursement of specialty services for individuals admitted on or after July 1, 1994. Hospital services are also subject to the provisions of Chapters 3, 8, 9, 30, 32 and 33 of these rules, except as otherwise specified in this Chapter.
(b) The Department may issue Provider Manuals, Provider Bulletins, or both, to providers and/or other affected parties 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) Terminology. Except as otherwise specified, the terminology used in this rule is the standard terminology and has the standard meaning used in accounting, health care, Medicaid and Medicare.
(b) General methodology. The Department reimburses providers of specialty services pursuant to contracts with selected providers. Except as otherwise specified by contract, selective services must be provided pursuant to this Chapter.
(a) 'Admission' or 'admitted.' The act by which an individual is admitted to a hospital as an inpatient or an outpatient. 'Admission' or 'admitted' does not include an individual that is transferred from one unit of a hospital to another unit in the hospital or to a distinct part hospital unit.
(b) 'Admission certification.' 'Admission certification' as defined by Chapter 8, which is incorporated by this reference.
(c) 'Certified.' Approved by the survey agency as in compliance with applicable statutes and rules.
(d) 'Chapter 1.' Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid rules.
(e) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(f) 'Chapter 4.' Chapter 4, Third Party Liability, of the Wyoming Medicaid Rules.
(g) 'Chapter 7.' Chapter 7, Inpatient Admission Certification, of the Wyoming Medicaid Rules.
(h) 'Chapter 9.' Chapter 9, Hospital Services, of the Wyoming Medicaid Rules.
(i) 'Chapter 30.' Chapter 30, Level of Care Inpatient Hospital Reimbursement, of the Wyoming Medicaid Rules.
(J) 'Claim.' A request by a provider for Medicaid payment for covered services provided to a recipient.
(k) 'Covered service.' A health service or supply eligible for Medicaid reimbursement pursuant to the rules and policies of the Department.
(l) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(m) 'Director.' The Director of the Department or the Director's designee.
(n) 'Division.' The Division of Health Care Financing of the Department, its agent, designee or successor.
(o) 'Emergency.' The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including pain) that referral or transfer of the individual to a contracting provider is impractical, and the absence of immediate medical attention could reasonably be expected to result in:
(i) Placing the patient's health in serious jeopardy; (ii) Serious impairment to bodily functions; or (iii) Serious dysfunction of any bodily organ or part
(p) 'Enrolled.' Enrolled as defined in Chapter 3, which definition is incorporated by this reference.
(q) 'Excess payments.' Medicaid funds received by a provider which exceed the Medicaid allowable payment established by the Department.
(r) 'HCFA.' The Health Care Financing Administration of the United States Department of Health and Human Services, its agent, designee or successor.
(s) 'HHS.' The United States Department of Health and Human Services, its agent, designee or successor.
(t) 'Hospital.' An institution that: (i) is approved to participate as a hospital under Medicare; (ii) is maintained primarily for the treatment and care of patients with disorders other than mental diseases or tuberculosis; (iii) has a provider agreement; (iv) is enrolled in the Medicaid program; and (v) is licensed to operate as a hospital by the State of Wyoming or, if the institution is out-of-state, licensed by the state in which the institution is located.
(u) "Inpatient." An "inpatient" as defined by 42 C.F.R. 440.10, which is incorporated by this reference.
(v) "Inpatient hospital service." "Inpatient hospital services" as defined by 42 C.F.R. 440.10, which is incorporated by this reference.
(w) "JCAHO." The Joint Commission on Accreditation of Healthcare Organizations.
(x) "Maintenance psychiatric services." Covered extended psychiatric services identified by revenue code 680.
(y) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(z) "Medical record." All documents, in whatever form, in the possession of or subject to the control of the hospital which describe the recipient's diagnosis, condition or treatment, including, but not limited to, the plan of care for the recipient.
(aa) "Outpatient." An "outpatient" as defined by 42 C.F.R. 440.2(a), which is incorporated by this reference.
(bb) "Outpatient hospital services." "Outpatient hospital services" as defined by 42 C.F.R. 440.20(a), which is incorporated by this reference.
(cc) "Patient." An individual admitted to a hospital or other provider of inpatient or outpatient hospital services.
(dd) "Physician." A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a comparable agency in another state, or a person licensed to practice dentistry by the Wyoming Board of Dental Examiners or a comparable agency in another state.
(ee) "Prior authorized." Approval by the Division pursuant to Chapter 3, Section 9, which is incorporated by this reference.
(ff) "Provider." A provider as defined by Chapter 3, Section 3(w), which is incorporated by this reference.
(gg) "Readmission." The act by which an individual is:
(hh) 'Recipient.' A person who has been determined eligible for Medicaid.
(ii) 'Specialty services.' Inpatient or outpatient hospital services as identified for selective contracting by the Department and approved by HCFA through appropriate waivers.
(jj) 'Survey agency.' The Health Facilities Survey, Certification and Licensure Office of the Department, its agent, designee or successor, or a comparable agency in another state.
(kk) 'Third party liability.' Third party liability as determined pursuant to Chapter 4, which is incorporated by this reference.
(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) Compliance with Chapter 3. A provider that wishes to receive Medicaid reimbursement for specialty services furnished to a recipient must meet the requirements of Chapter 3, Sections 4 through 6, which are incorporated by this reference.
(c) 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 must comply with Chapter 3, Section 7, which is incorporated by this reference.
(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 suitable for 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 7. Verification of recipient data. A provider must comply with Chapter 3, Section 8, which is incorporated by this reference.
(a) The Department shall reimburse specialty services through selective contracting with qualified providers. Except as otherwise provided in this Section, only providers that enter a contract with the Department shall be reimbursed for providing specialty services.
(b) All-inclusive rate. Providers of specialty services shall not receive Medicaid reimbursement for furnishing specialty services in addition to the contract rate, except as provided in Chapter 32.
(c) Services that require prior authorization or admission certification. The Division may, as part of the selective contracting process, 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.
(a) Contracting process. The Department shall contract for specialty services as follows:
(i) Identify covered services to be reimbursed as specialty services;
(ii) Identify interested, qualified providers;
(iii) Develop a selective contracting model;
(iv) Solicit proposals using the selective contracting model;
(v) Evaluate proposals and negotiate contracts.
(b) Duration of contracts. Contracts for selective services shall be for twelve months, and may be extended pursuant to the applicable contract.
Section 10. Reimbursement of readmissions. Medicaid shall not reimburse for a readmission if the readmission is for the 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 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 4, which is incorporated by this reference.
(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 13. Payment of Claims. Payment of claims shall be pursuant to Chapter 3, Section 11, which is incorporated by this reference.
Section 14. Recovery of excess payments. The Department may recover excess payments pursuant to Chapter 3, Section 12, which is incorporated by this reference.
(a) Request for reconsideration. A provider may request reconsideration of a request to recover excess payments. Such a request must be mailed to the Department, by certified mail, return receipt requested, within twenty days after the date the provider receives notice pursuant to Section 14. 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 matter and send written notice by certified mail, return receipt requested, to the provider 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 as apart 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 the time specified in the request. Failure to provide the requested information shall result in the dismissal of the request with prejudice.
(d) Matters subject to reconsideration. A provider may request reconsideration of a decision to recover excess payments.
(e) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.
(f) Administrative hearing. A provider may request an administrative hearing regarding the final agency decision pursuant to Chapter 1 of these rules by mailing by certified mail, return receipt requested or personally delivering a request for hearing to the Department within twenty days after the date the provider receives notice of the final agency decision. At the hearing, the burden shall be on the provider to show that the agency's final decision does not comply with this Chapter.
(g) 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 1.
Section 16. 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, except as otherwise specified in this Chapter.
Section 17. 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 Act allows the Department to contract with selected providers to furnish certain hospital services pursuant to a waiver granted by HCFA. The Department has applied for and received a waiver which permits the reimbursement of specialty services pursuant to contracts with selected providers. Specialty services include organ transplants, neo-natal intensive care services and inpatient psychiatric services.
This Chapter is being promulgated to specify the procedures the Department will follow in contracting with selected providers for specialty services (Providers of inpatient hospital services other than specialty services are reimbursed pursuant to Chapter 30 of the Department's Medicaid rules.).
Chapter 31 will apply to payment for specialty services furnished on or after July 1, 1994. Payments for services furnished before then will be reimbursed pursuant to Chapter 24. July 1, 1994