Wyo. Code R. 048-0037-33
Medicaid
Chapter 33: Reimbursement of Outpatient Hospital Services
Effective Date: 06/28/1994 to 02/18/1997
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.33.06281994
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 outpatient hospital services furnished to individuals admitted on or after July 1, 1994. 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.
(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.
(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.
July 1, 1994
(d) 'Chapter 3.' Chapter 3. Provider Participation, of the Wyoming Medicaid Rules.
(e) 'Chapter 4.' Chapter 4, Third Party Liability, of the Wyoming Medicaid Rules.
(f) 'Chapter 9.' Chapter 9, Hospital Services, of the Wyoming Medicaid Rules.
(g) 'Chapter 24.' Chapter 24, Wyoming Hospital Reimbursement System, of the Wyoming Medicaid Rules.
(h) 'Chapter 30.' Chapter 30, Level of Care Inpatient Hospital Reimbursement, of the Wyoming Medicaid Rules.
(i) 'Chapter 31.' Chapter 31, Selective Contracting of Hospital Services, of the Wyoming Medicaid Rules.
(j) 'Chapter 32.' Chapter 32, Reimbursement of Disproportionate Share Hospitals, of the Wyoming Medicaid Rules.
(k) 'Claim.' A request by a provider for Medicaid payment for covered services provided to a recipient.
(l) 'Covered service.' A health service or supply eligible for Medicaid reimbursement pursuant to the rules and policies of the Department.
(m) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(n) 'Director.' The Director of the Department or the Director's designee.
(o) 'Division.' The Division of Health Care Financing of the Department, its agent, designee or successor.
(p) 'Emergency services.' Outpatient hospital services designated by the Division based on ICD-9-CM codes and disseminated by Provider Manuals or Provider Bulletins.
(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:
(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.
(r) 'Enrolled.' Enrolled as defined in Chapter 2, which definition is incorporated by this reference.
(s) '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 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 the Wyoming Medical Assistance and Services Act.
(z) 'Medicaid fee schedule.' The Medicaid fee schedule as established pursuant to Chapter 3, as in effect on July 1, 1994, and as modified pursuant to that Section.
(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(w), which is incorporated by this reference.
(hh) 'Readmission.' The act by which an individual is:
(i) Admitted to a provider from which the individual had been discharged;
(ii) On or before the thirty-first day after the previous discharge; and
(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.
(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.
(a) Generally. The Medicaid allowable payment for outpatient hospital services shall be pursuant to 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 pursuant to the Medicaid fee schedule.
(e) Emergency services. The Medicaid allowable payment for emergency services shall be pursuant to 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 pursuant to the Medicaid fee schedule.
(g) Laboratory. The Medicaid allowable payment for laboratory services shall be pursuant to 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.
(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. 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 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 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 13. 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 14. 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 and HCFA regulations require the Department to reimburse providers of outpatient hospital services using methods that are consistent with efficiency, economy and quality of care. Payment rates also may not exceed the amount that would be paid under Medicare. Chapter 33 establishes the methodology for reimbursing providers of outpatient hospital services in conformance with Federal requirements.
Chapter 33 provides for the reimbursement of outpatient hospital services pursuant to the Medicaid fee schedule. Chapter 33 will be used to reimburse providers of outpatient hospital services provided to recipients admitted on or after July 1, 1994. Chapter 33 replaces Chapter 24 with respect to reimbursement of outpatient hospital services, except that Chapter 24 will remain in effect for determining payments for outpatient hospital services provided to recipients admitted before July 1, 1994.
July 1, 1994