Wyo. Code R. 048-0037-36
Medicaid
Chapter 36: Administrative Transportation
Effective Date: 02/16/2005 to 06/14/2017
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.36.02162005
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.
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. These rules shall apply to all administrative transportation provided on or after its effective date.
(a) This rule shall apply to and govern the provision of administrative transportation and reimbursement for those services.
(b) The Department may issue manuals or bulletins to providers and/or other affected parties to interpret the provisions of this rule. Such manuals and bulletins shall be consistent with and reflect the policies contained in this rule. The provisions contained in manuals or bulletins shall be subordinate to the provisions of the rules and regulations.
(c) The incorporation by reference of any external standard is intended to be the incorporation of that standard as it is in effect on the effective date of these rules and regulations.
The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indicates that such is the intent, words in the singular number shall include the plural and vice versa. Throughout these rules gender pronouns are used interchangeably. The drafters have attempted to utilize each gender pronoun in equal numbers, in random distribution. Words in each gender include individuals of the other gender.
For the purpose of these rules, the following shall apply:
(a) 'Administrative transportation.' Transportation, other than transportation in an ambulance, to and/or from a provider of covered services.
(b) 'Ambulance.' An ambulance as defined by Chapter 15, which definition is incorporated by this reference.
(c) 'Appropriate provider.' A provider that offers services sufficient to meet the medical needs of a patient.
(d) 'Chapter I.' Chapter I, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
(e) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(f) 'Chapter 6.' Chapter 6, HEALTH CHECK (EPSDT) SERVICES, of the Wyoming Medicaid Rules.
(g) 'Chapter 15.' Chapter 15, Ambulance Services, of the Wyoming Medicaid Rules.
(h) 'Chapter 16.' Chapter 16, Medicaid Program Integrity, of the Wyoming Medicaid Rules.
(i) 'Chapter 26.' Chapter 26, Covered Services, of the Wyoming Medicaid Rules.
(j) 'Chapter 39.' Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid Rules.
(k) 'Claim.' A request by a recipient for reimbursement for administrative transportation.
(l) 'Covered services.' Services which are Medicaid reimbursable pursuant to the rules of the Department.
(m) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(n) 'Department of Transportation (DOT).' The Wyoming Department of Transportation, its agent, designee or successor.
(o) 'Emergency.' The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe 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.
(p) "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:
(i) Overpayments;
(ii) Payments made as a result of system errors;
(iii) Payments for services furnished to a non-recipient;
(iv) Payments for non-covered services furnished to a recipient;
(v) Payments for services which are not documented and/or supported by medical records and/or financial records;
(vi) Payments for services for which admission certification has been denied or withdrawn;
(vii) Payments which exceed a provider's usual and customary charge, unless otherwise permitted by the Department's rules.
(q) "Expanded services." "Expanded services" as defined by Chapter 6, which definition is incorporated by this reference.
(r) "In-town." Within the city limits of an incorporated city or town.
(s) "Local trade area." The geographic area surrounding the recipient's residence, excluding portions of states other than Wyoming, that is commonly used by other persons in the same area to obtain similar services.
(t) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act. "Medicaid" includes any successor or replacement program enacted by Congress and/or the Wyoming Legislature.
(u) "Medicaid reimbursement." The maximum Medicaid reimbursement for administrative transportation as specified by this Chapter.
(v) "Medical appointment." A scheduled appointment with a provider.
(w) 'Medical necessity' or 'medically necessary.' A 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 recipient's 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) Provided in the most appropriate and cost-effective setting required by the recipient's condition.
(x) 'Nursing facility.' 'Nursing facility' as defined by 42 U.S.C. § 1396r(a), which is incorporated by this reference.
(y) 'Overpayment.' Overpayment as defined in Chapter 39, which definition is incorporated by this reference.
(z) 'Physician.' A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a similar agency in another state.
(aa) 'Prior authorized.' Approval by the Department pursuant to the prior authorization provisions of Chapter 3, which are incorporated by this reference.
(bb) 'Provider.' A provider as defined by Chapter 3, which definition is incorporated by this reference.
(cc) 'Recipient.' An individual that has been determined eligible for Medicaid.
(dd) 'Recipient under age twenty-one.' An individual under age twenty-one that has been determined eligible for Medicaid. A recipient is under age twenty-one before or during the month in which he or she turns twenty-one years of age.
(ee) 'Reimbursement request and certification.' Documentation, in the form specified by the Department, that contains:
(i) An itemized statement of the particulars of the administrative transportation for which a recipient is requesting reimbursement; and (ii) The original signature of the recipient or other payee that receives the reimbursement.
(ff) 'Service area.' The State of Wyoming and the following cities or towns: Craig, Colorado; Idaho Falls, Montpelier and Pocatello, Idaho; Billings and Bozeman, Montana; Kimball and Scottsbluff, Nebraska; Belle Fourche, Custer, Deadwood, Rapid City and Spearfish, South Dakota; and Ogden and Salt Lake City, Utah.
(gg) 'Services.' Health services.
(hh) 'Subsidized public transportation.' Public transportation carriers that receive a subsidy from the Department of Transportation.
(ii) 'Urgent case.' A situation, other than an emergency, where a recipient requires the immediate care of a provider.
(jj) 'Usual and customary charges.' The charges for comparable transportation or other services provided to non-recipients.
(kk) 'Working day.' 8:00 a.m. to 5:00 p.m., Mountain Time, Monday through Friday, excluding State holidays.
(ll) 'Wyoming Rural Transit Program.' The transportation program operated by the Wyoming Department of Transportation.
Compliance with Chapter 3. An individual or entity that wishes to receive Medicaid reimbursement for furnishing covered services to recipients must meet the provider participation requirements of Chapter 3, which requirements are incorporated by this reference.
(a) Ambulance transportation. Transportation in an ambulance is a covered service as specified in Chapter 15.
(b) General rule. Administrative transportation to and/or from a medical appointment is reimbursable if:
(i) The covered services furnished to the recipient 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 via 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 appropriate mode of transportation that is reasonably available.
(iii) Per diem expenses. Per diem expenses are reimbursable to a recipient or a recipient's legal guardian if:
(A) The individual who is to receive services is a recipient under age twenty-one; and
(B) The services to be received are expanded services.
(d) Transportation to medical appointments outside Wyoming and within the service area is reimbursable if:
(i) The covered service is not available in the local trade area; and (ii) The specified city within the service area is closer (in highway miles) than the nearest location within Wyoming where the service is available.
(e) Transportation to medical appointments outside the service area is not reimbursable unless:
(i) A person licensed to practice medicine, dentistry, psychiatry, osteopathy, optometry has referred the recipient 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 recipient'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 recipient or consult with the recipient's physician or other provider of medical services, unless the transportation is to visit a recipient 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 recipient 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 recipient due to the recipient's refusal to follow medical advice or the recipient's unacceptable conduct;
(g) Missed appointments. If a recipient misses or cancels a medical appointment for which Medicaid reimbursement has been paid pursuant to this rule, the recipient must refund the funds to the Department within fifteen days of the missed appointment (unless the medical appointment has been rescheduled). Medicaid funds that are not timely 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 recipient that wishes to receive reimbursement for administrative travel must contact the Department and make a request. The request may be oral or written, and the recipient shall furnish information as requested by the Department and complete whatever documentation is required by the Department.
(b) Payment. Payment shall be by warrant issued to the recipient or other payee.
(c) Reimbursement request and certification. After the recipient or other payee submits a request for administrative transportation, the recipient or payee must sign reimbursement request and certification and return it to the Department. Reimbursement request and certifications shall become part of the recipient's file and retained by the Department.
(a) Incorporation of Chapter 3. Prior authorization of administrative transportation shall be governed by the prior authorization requirements of Chapter 3, which are incorporated by this reference.
(b) Services that require prior authorization.
(i) All administrative transportation requires prior authorization. (ii) In deciding whether to authorize administrative the Department shall consider the: (A) Cost of the transportation; (B) Potential for over-utilization of the transportation; (C) Availability of lower cost alternatives; and (D) Excess payments owed by the Recipient.
(iii) The failure to obtain prior authorization shall result in denial of Medicaid reimbursement.
(a) Generally. Medicaid reimbursement for administrative transportation shall be as follows:
(i) Reimbursement to a recipient:
(A) Prospective reimbursement. The recipient's projected expenses. (B) Retroactive reimbursement. The recipient's actual expenses.
(ii) Reimbursement to a provider. The lesser of the charge to the recipient and the usual and customary charge for the transportation.
(b) Private automobile. Medicaid reimbursement for administrative transportation furnished in a private automobile shall be:
(i) 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) 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) Shall not be paid for fractions of a mile.
(c) Per diem expenses. Medicaid reimbursement for per diem expenses is limited to $25.00 per day, to be used for meals and commercial lodging.
(d) Retrospective reimbursement. Reimbursement for administrative transportation that is already completed is reimbursable 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 the expenses of the travel.
Section 11. Payment of claims. Payment of claims shall be pursuant to the payment of claims provisions of Chapter 3, which are incorporated by this reference.
Section 12. Recovery of excess payments or overpayments.
(a) The Department may recover excess payments pursuant to Chapter 16 or Chapter 39.
(b) The Department may recover overpayments pursuant to Chapter 16 or Chapter 39.
Section 13. Reconsideration.
(a) A provider 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, which are incorporated by this reference.
(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, which provisions are incorporated by this reference.
Section 15. Administrative hearing.
(a) Recipients. A recipient may request an administrative hearing pursuant to Chapter 1 regarding the termination, reduction or denial of covered services.
(b) Procedures. A request for an administrative hearing must be made in conformance with Chapter 1, and the hearing shall be held pursuant to Chapter 1.
Section 16. 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 17. Superseding effect. When promulgated, 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.
Section 18. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in full force and effect.