Health, Department of

Medicaid

Chapter 36: Administrative Transportation

Effective Date: 06/14/2017 to Current

Rule Type: Current Rules & Regulations

Reference Number: 048.0037.36.06142017

Chapter 36

Administrative Transportation

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 -306.

Section 2. Purpose and Applicability.

This Chapter establishes the scope of administrative transportation covered by Medicaid and the methods and standards of reimbursing for such services. Any person, facility, or agency that furnishes transportation and seeks Medicaid reimbursement for doing so shall be subject to these rules. This Chapter shall apply to all administrative transportation provided on or after its effective date.

Section 3. General Provisions.

(a) The Department may issue manuals or bulletins to providers or other affected parties 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 or bulletins shall be subordinate to the provisions of the Wyoming Medicaid Rules.

Section 4. Definitions.

Except as otherwise specified in Chapter 1 or this Chapter, the terminology used is the standard terminology and has the standard meaning used in healthcare, Medicaid, and Medicare.

(a) “Ambulance.” An ambulance as defined by Chapter 15.

(b) “Department of Transportation (DOT).” The Wyoming Department of Transportation, its agent, designee or successor.

(c) “Excess payments.” Medicaid funds received by a provider, to which the provider is not entitled for any reason, including payments which exceed the Medicaid allowable payment. “Excess payments” includes, but is not limited to:

1. (i) Overpayments;
2. (ii) Payments made as a result of system errors;

3. (iii) Payments for services furnished to an individual that is not a client;

4. (iv) Payments for non-covered services furnished to a client;

5. (v) Payments for services which are not documented or supported by medical records or financial records;
6. (vi) Payments for services for which admission certification has been denied or withdrawn;
7. (vii) Payments which exceed a provider's usual and customary charge, unless otherwise permitted by the Department's rules.(d) 'Local trade area.' The geographic area surrounding the client's residence, excluding portions of states other than Wyoming, that is commonly used by other persons in the same area to obtain similar services.(e) 'Medical appointment.' A scheduled appointment with a provider.(f) 'Reimbursement request and certification.' Documentation, in the form specified by the Department, that contains:- (i) An itemized statement of the administrative transportation for which a client is requesting reimbursement; and
8. (ii) The original signature of the client or other payee that receives the reimbursement.(g) 'Subsidized public transportation.' Public transportation carriers that receive a subsidy from the Department of Transportation.(h) 'Wyoming Rural Transit Program.' The transportation program operated by the Wyoming Department of Transportation.

Section 5. Provider participation.

An individual or entity that wishes to receive Medicaid reimbursement for furnishing covered services to clients shall meet the provider participation requirements of Chapter 3.

Section 6. Reimbursable transportation expenses.

(a) Ambulance transportation. Transportation in an ambulance is a covered service as specified in Chapter 15.

(b) Administrative transportation to and from a medical appointment is reimbursable if:

(i) The covered services furnished to the client at the medical appointment are medically necessary;

(ii) Transportation has been approved by the Department at least three working days in advance of the necessary transportation; and

(iii) The transportation is the least costly mode of transportation selected and approved by the Department pursuant to subsection (c).

(c) Selection and approval of administrative transportation.

(i) The Department shall be responsible for selecting and approving the mode of administrative transportation.

(ii) In selecting and approving transportation, the Department:

(A) May consider the following modes of transportation:

(I) Public transportation, including subsidized public transportation and the Wyoming Rural Transit Program;

(II) Private automobile;

(III) Taxi;

(IV) Bus;

(V) Shuttle services; and

(VI) Airline; and

(B) Shall select the least expensive and most appropriate mode of transportation reasonably available.

(iii) Per diem expenses. Per diem expenses are reimbursable to a client or a client’s legal guardian if:

(A) The client receiving services is a client under age twenty-one; and

(B) The services to be received are covered services.

(d) Transportation to medical appointments outside Wyoming and within the Wyoming Medicaid Service Area (WMSA) is reimbursable if:

(i) The covered service is not available in the local trade area; and

(ii) The specified city within the WMSA is closer (in highway miles) than the nearest location within Wyoming where the service is available.

(e) Transportation to medical appointments outside the WMSA is not reimbursable unless:

(i) A person licensed to practice medicine, dentistry, psychiatry, osteopathy, or optometry has referred the client to a specified provider for covered services that are not available in the service area; and

(ii) The referral is in writing and the medical necessity of the referral is documented in the client’s medical records.

Section 7. Excluded transportation expenses. The following transportation expenses are not reimbursable:

(a) Transportation to receive services which are not covered services;

(b) Transportation of a family member or friend to visit a client or consult with the client’s physician or other provider of medical services, unless the transportation is to visit a client under age twenty-one and the visit is medically necessary;

(c) Transportation to pick up pharmaceuticals;

(d) Transportation of a resident of a nursing facility to receive services that are available at the nursing facility;

(e) Transportation of a client in response to detention ordered by a court or law enforcement agency;

(f) Transportation to receive covered services from a provider because another provider has denied services to the client due to the client’s refusal to follow medical advice or the client’s unacceptable conduct;

(g) Missed appointments. If a client misses or cancels a medical appointment for which Medicaid reimbursement has been paid pursuant to this rule, the client shall refund the cost of the appointment to the Department within fifteen days of the missed appointment (unless the medical appointment has been rescheduled). Medicaid funds that are not refunded shall be considered excess payments and may be recovered pursuant to Section 12.

Section 8. Procedures for obtaining reimbursement.

(a) Request for reimbursement. A client wishing to receive reimbursement for administrative travel shall contact the Department and request reimbursement. The request may be oral or written. The client shall furnish information as requested by the Department and complete the Department's required documentation.

(b) Payment. Payment shall be by warrant issued to the client or other payee.

(c) Reimbursement request and certification. After the client or other payee submits a request for administrative transportation, the client or payee shall sign the reimbursement request and certification and return it to the Department. Reimbursement requests and certifications shall become part of the client's file and be retained by the Department.

(d) Reimbursement to enrolled providers. Providers of lodging, taxi or non-taxi transportation services may enroll with the Wyoming Medicaid Program to be reimbursed for covered transportation services directly by Wyoming Medicaid.

(e) Provider Payment. Providers shall submit all claims to Wyoming Medicaid and reimbursement will be according to Wyoming Medicaid reimbursement rates for the covered procedure codes billed on the submitted claim as published in the Wyoming Medicaid Fee Schedule.

Section 9. Prior authorization.

(a) Prior authorization of administrative transportation shall be governed by the prior authorization requirements of Chapter 3.

(b) All administrative transportation requires prior authorization.

(i) In deciding whether to authorize administrative transportation, the Department shall consider the:

1. (A) Cost of the transportation;
2. (B) Potential for over-utilization of the transportation;
3. (C) Availability of lower cost alternatives; and
4. (D) Excess payments owed by the client.

(ii) The failure to obtain prior authorization shall result in denial of Medicaid reimbursement.

Section 10. Allowable Medicaid reimbursement.

(a) Medicaid reimbursement for administrative transportation shall be as follows:

(i) Reimbursement to a client shall be by one of the following methods:

(A) Prospective reimbursement. The client may be reimbursed for projected administrative transportation expenses.

(B) Retroactive reimbursement. The client may be reimbursed for actual administrative transportation expenses.

(ii) Reimbursement to a provider shall be the lesser of the provider’s billed charge and Wyoming Medicaid’s allowed amount per the published Wyoming Medicaid Fee Schedule.

(b) Private automobile. Medicaid reimbursement for administrative transportation furnished in a private automobile shall:

(i) Be based on mileage as determined by the Wyoming State Auditor, or if not so determined, on map mileage using major highways as determined by the Department;

(ii) Be limited to the maximum amount recommended by the State Auditor in order to avoid any requirement for reporting mileage income to the Internal Revenue Service; and

(iii) Not be paid for fractions of a mile.

(c) Per diem expenses. Medicaid reimbursement for per diem expenses is limited to $25.00 per person, per day, to be used for meals and commercial lodging. Lesser amounts will be reimbursed for additional clients transported together.

(d) Retroactive reimbursement. Reimbursement for administrative transportation that is already completed is reimbursable to clients or providers if:

(i) Requested within thirty days after the date the travel was completed; and

(ii) The request contains the information and documentation required by the Department, including a valid receipt for travel expenses.

Section 11. Payment of claims. Payment of claims shall be pursuant to the payment of claims provisions of Chapter 3.

Section 12. Recovery of excess payments or overpayments.

(a) The Department may recover excess payments and overpayments pursuant to Chapter 16.

Section 13. Reconsideration.

(a) A provider or client may request that the Department reconsider a decision to recover excess payments or overpayments. The request for reconsideration, the reconsideration, and any administrative hearing shall be pursuant to the reconsideration provisions of Chapter 3.

(b) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.

Section 14. Disposition of recovered funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16.

Section 15. Administrative hearing.

(a) Clients. A client may request an administrative hearing pursuant to Chapter 4 regarding the termination, reduction or denial of covered services.

(b) Procedures. A request for an administrative hearing shall be made in conformance with Chapter 4, and the hearing shall be held pursuant to Chapter 4.

Section 16. 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 17. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in full force and effect.

Section 18. Incorporation by Reference.

(a) For any code, standard, rule, or regulation incorporated by reference in these rules:

(i) The Department of Health has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of these rules;

(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of the section; and

(iii) The incorporated code, standard, rule, or regulation is maintained at the Department of Health and is available for public inspection and copying at cost at the same location.

(b) Each rule incorporated by reference is further identified as follows:

(i) Referenced in Section 4 is Chapter 1 – Rules and Regulations for Medicaid – Definitions, adopted by the Department of Health and effective on November 7, 2011, found at http://soswy.state.wy.us/Rules/RULES/8384.pdf.

(ii) Referenced in Sections 5, 9, 11, and 13 is Chapter 3 – Provider Participation, adopted by the Department of Health and effective on December 16, 1998, found at http://soswy.state.wy.us/Rules/RULES/3349.pdf.

(iii) Referenced in Section 15 is Chapter 4 – Medicaid Administrative Hearings, adopted by the Department of Health and effective on November 7, 2011, found at http://soswy.state.wy.us/Rules/RULES/8385.pdf.

(iv) Referenced in Sections 4 and 6 is Chapter 15 – Ambulance Services, adopted by the Department of Health and effective on September 8, 1995, found at http://soswy.state.wy.us/Rules/RULES/1529.pdf.

(v) Referenced in Sections 12 and 14 is Chapter 16 – Program Integrity, adopted by the Department of Health and effective on November 7, 2011, found at http://soswy.state.wy.us/Rules/RULES/8386.pdf.