Health, Department of

Medicaid

Chapter 33: Reimbursement of Outpatient Hospital Services

Effective Date: 02/18/1997 to 01/06/2015

Rule Type: Superceded Rules & Regulations

Reference Number: 048.0037.33.02181997

WYOMING MEDICAID RULES

CHAPTER 33

REIMBURSEMENT OF OUTPATIENT HOSPITAL SERVICES

Section 1. Authority

This Chapter 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.

Section 2. Purpose and Applicability.

(a) This Chapter shall apply to and govern Medicaid reimbursement of outpatient hospital services furnished to individuals admitted on or after its effective date. Hospital services are also subject to the provisions of Chapters 3, 9, 24, 30, 31 and 32 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.

Section 3. General Provisions.

(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 outpatient hospital services on a fee for service.

Section 4. Definitions.

(a) 'Admission' or 'admitted.' The act by which an individual is admitted to a hospital as 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) 'Certified.' Approved by the survey agency as in compliance with applicable statutes and rules.

(c) 'Chapter 1.' Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid rules.

1. (d) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
2. (e) 'Chapter 4.' Chapter 4, Third Party Liability, of the Wyoming Medicaid Rules.
3. (f) 'Chapter 9.' Chapter 9, Hospital Services, of the Wyoming Medicaid Rules.
4. (g) 'Chapter 24.' Chapter 24, Wyoming Hospital Reimbursement System, of the Wyoming Medicaid Rules.
5. (h) 'Chapter 30.' Chapter 30, Level of Care Inpatient Hospital Reimbursement, of the Wyoming Medicaid Rules.
6. (i) 'Chapter 31.' Chapter 31, Selective Contracting of Hospital Services, of the Wyoming Medicaid Rules.
7. (j) 'Chapter 32.' Chapter 32, Reimbursement of Disproportionate Share Hospitals, of the Wyoming Medicaid Rules.
8. (k) 'Claim.' A request by a provider for Medicaid payment for covered services provided to a recipient.
9. (l) 'Covered service.' A health service or supply eligible for Medicaid reimbursement pursuant to the rules and policies of the Department.
10. (m) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
11. (n) 'Director.' The Director of the Department or the Director's designee.
12. (o) 'Division.' The Division of Health Care Financing of the Department, its agent, designee or successor.
13. (p) 'Emergency services.' Outpatient hospital services designated by the Division based on ICD-9-CM codes and disseminated by Provider Manuals or Provider Bulletins.
14. (q) 'Emergency.' The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including pain) that the absence of immediate medical attention could reasonably be expected to result in:
15. (i) Placing the patient's health in serious jeopardy;
16. (ii) Serious impairment to bodily functions; or
17. (iii) Serious dysfunction of any bodily organ or part.
18. (r) 'Enrolled.' Enrolled as defined in Chapter 3, which definition is incorporated by this reference.

(x) “Excess payments.” Medicaid funds received by a provider which exceed the Medicaid allowable payment established by the Department.

(t) “HCFA.” The Health Care Financing Administration of the United States Department of Health and Human Services, its agent, designee or successor.

(u) “HHS.” The United States Department of Health and Human Services, its agent, designee or successor.

(v) “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 as a hospital by the state in which the institution is located.

(w) “Inpatient hospital services.” “Inpatient hospital services” as defined by 42 C.F.R. § 440.10, which is incorporated by this reference.

(x) “ICD-9-CM.” The International classification of Diseases, 9th Clinical Modification. The ICD-9-CM is published by HCFA and is available from the United States Government Printing Office, Washington, D.C. 20402.

(y) “Medicaid.” Medical assistance and services provided pursuant to Title XIX of the Social Security Act and/or the Wyoming Medical Assistance and Services Act. “Medicaid” includes any successor or replacement program enacted by Congress and/or the Wyoming Legislature.

(z) “Medicaid fee schedule.” The Medicaid fee schedule as established pursuant to Chapter 3, as in effect on the effective date of this Chapter, and as modified pursuant to that Chapter.

(aa) “Medically necessary” or “medical necessity.” A health service that is required to diagnose, treat, cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected; to relieve pain; or to improve and preserve health and be essential to life. The service must be:

(i) Consistent with the diagnosis and treatment of the recipient’s condition;

(ii) In accordance with the standards of good medical practice among the provider’s peer group;

(iii) Required to meet the medical needs of the recipient and undertaken for reasons other than the convenience of the recipient and the provider; and

(iv) Performed in the least costly setting required by the recipient’s condition.

(bb) “Outpatient.” An outpatient as defined by 42 C.F.R. § 440.2(a), which is incorporated by this reference.

(cc) “Outpatient hospital services.” Outpatient hospital services as defined by 42 C.F.R. §

440.20(a), which is incorporated by this reference.

(dd) “Patient.” An individual admitted to a hospital or other provider of outpatient hospital services.

(ee) “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.

(ff) “Prior authorized.” Approval by the Division pursuant to Chapter 3, Section 9, which is incorporated by this reference.

(gg) “Provider.” A provider as defined by Chapter 3, Section 3(y), which is incorporated by this reference.

(hh) “Readmission.” The act by which an individual is:

1. (i) Admitted to a provider from which the individual had been discharged;
2. (ii) On or before the thirty-first day after the previous discharge; and
3. (iii) For treatment of any diagnosis.

(ii) “Recipient.” A person who has been determined eligible for Medicaid.

(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.

(ll) “Usual and customary charge.” A provider’s charge to the general public for the same service.

Section 5. Provider Participation.

(a) Payments only to providers. No provider that furnishes outpatient hospital services to a recipient shall receive Medicaid funds unless the provider is certified, has signed a provider agreement and is enrolled.

(b) Compliance with Chapter 3. A provider that wishes to receive Medicaid reimbursement for outpatient hospital services furnished to a recipient must meet the requirements of Chapter 3, Sections 4 through 6, which are incorporated by this reference.

Section 6. Provider Records. A provider must comply with Chapter 3, Section 7, which is incorporated by this reference.

Section 7. Verification of recipient data. A provider must comply with Chapter 3, Section 8, which is incorporated by this reference.

Section 8. Medicaid allowable payment for outpatient hospital services.

(a) Generally. The Medicaid allowable payment for outpatient hospital services shall be the lower of the provider’s usual and customary charge and the Medicaid fee schedule.

(b) Medicaid reimbursement is not available for services that are not medically necessary.

(c) Services that require prior authorization. The Division may, from time to time, designate outpatient hospital services that require prior authorization. In designating such services, the Division shall consider the cost of the service, the potential for over-utilization of the service, and the availability of lower cost alternatives. The Division shall disseminate a current list of services that require prior authorization to providers through Provider Manuals or Provider Bulletins. The failure to obtain prior authorization shall result in denial of Medicaid payment for the service.

(d) Outpatient surgery. The Medicaid allowable payment for outpatient surgery shall be the lower of the provider’s usual and customary charge and the Medicaid fee schedule.

(e) Emergency services. The Medicaid allowable payment for emergency services shall be the lower of the provider’s usual and customary charge and the Medicaid fee schedule. Ancillary charges and physician’s charges may be billed separately.

(f) Radiology. The Medicaid allowable payment for radiology services shall be the lower of the provider’s usual and customary charge and the Medicaid fee schedule.

(g) Laboratory. The Medicaid allowable payment for laboratory services shall be the lower of the provider’s usual and customary charge and the Medicaid fee schedule.

(h) Claims for outpatient and inpatient hospital services. A claim seeking reimbursement for outpatient hospital services provided to a recipient within twenty-four hours before the recipient received inpatient hospital services for the same or similar diagnosis shall be denied.

Section 9. Third party liability.

(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 10. Payment of Claims. Payment of claims shall be pursuant to Chapter 3, Section 11, which is incorporated by this reference.

Section 11. Audits.

(a) The Department or HCFA may audit a provider at any time to determine whether the hospital has received excess payments.

(b) The Department or HCFA may perform audits through employees, agents, or through a third party. Audits shall be performed in accordance with generally accepted auditing standards.

(c) Disallowances. If an audit discloses excess payments, the Department shall recover any excess payments pursuant to Section 12.

(d) Notice of excess payments. After determining that a provider has received excess payments, the Department shall send written notice to the provider, by certified mail, return receipt requested, stating the amount of the excess payments, the basis for the determination of excess payments and the provider's right to request reconsideration of that determination pursuant to Section 13. The reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.

(e) Recovery of excess payments. A provider must reimburse the Department for excess payments within thirty days after the provider receives written notice from the Department pursuant to subsection (d), even if the provider has requested reconsideration or an administrative hearing regarding the determination of excess payments. If the provider fails to timely repay excess payments, the Department shall recover the excess payments pursuant to Section 12.

(f) Reporting audit results. If at anytime during a financial audit or a medical audit, the Division discovers evidence suggesting fraud or abuse by a provider, that evidence, in addition to the Division's final audit report regarding that provider, shall be referred to the Medicaid Fraud Control Unit of the Wyoming Attorney General's Office.

Section 12. Recovery of excess payments. The Department shall recover excess payments pursuant to Chapter 3, Section 12, which is incorporated by this reference.

Section 13. Reconsideration.

(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 11. 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 a 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 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) Informal resolution. The provider or the Department 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 of a subsequent administrative hearing or judicial proceeding.

(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.

(h) Confidentiality of settlement agreements. If the Division and a provider enter into a settlement agreement as part of a reconsideration or an administrative hearing, such agreement shall be confidential, except as otherwise required by law. A breach of confidentiality by the provider shall, at the Division's option, result in the settlement agreement becoming null and void.

Section 14. Interpretation of Chapter.

(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 provider manuals and provider bulletins, which are inconsistent with this Chapter, except as otherwise specified in this Chapter.

Section 16. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.