Wyo. Code R. 048-0037-3
Medicaid
Chapter 3: Provider Participation
Effective Date: 07/01/1992 to 09/08/1995
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.3.07011992
Section 1. Authority.
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.
Section 2. Applicability.
This rule shall apply to and govern the participation in the Medicaid program of providers of covered services, except as otherwise specified in the rules of the Department.
Section 3. Definitions.
(a) "Business agent." A person or entity that submits a claim for or receives Medicaid funds on behalf of a provider.
(b) "Chapter I." Chapter I, Medicaid Fair Hearings, of the Wyoming Medicaid rules.
(c) "Chapter IV." Chapter IV, Third Party Liability, of the Wyoming Medicaid rules.
(d) "Chapter V." Chapter V, Nursing Home Remedies and Terminations, of the Wyoming Medicaid rules.
(e) "Chapter XVI." Chapter XVI, Medicaid Program Integrity, of the Wyoming Medicaid rules.
(f) "Claim." A request by a provider for Medicaid payment for services provided to a recipient.
(g) "Covered service." Services which are reimbursable pursuant to the rules of the Department.
(h) "Department." The Wyoming Department of Health, its, agent, designee or successor.
(i) "Department of Family Services." The Wyoming Department of Family Services, its agent, designee or successor.
(j) "Division" The Division of Health Care Financing of the Department, its agent, designee or successor.
(k) "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.
(l) "Enrolled." A provider that has signed a provider agreement and has been enrolled as a provider with the Division.
(m) "Excess payments." Medicaid funds received by a provider which exceed the Medicaid allowable payment.
(n) "Financial records." All records, in whatever form, used or maintained by a provider in the conduct of its business affairs and which are necessary to substantiate or understand claims submitted to the Department.
(o) "HCFA." The Health Care Financing Administration of the United States Department of Health and Human Services.
(p) "Local agency." The County office of the Department of Family Services.
(q) "Local trade area." The geographic area surrounding the recipient's residence, including portions of states other than Wyoming commonly used by other persons in the same area to obtain similar services.
(r) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act of 1967, as amended.
(s) "Medicaid allowable payment." The maximum Medicaid reimbursement as determined pursuant to this and the other rules of the Department.
(t) "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.
(u) "Medical records." All medical records, in whatever form, in the possession of or subject to the control of a provider which describe the recipient's diagnosis, treatment or condition.
(v) 'Medicare.' The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.
(w) 'Provider.' Any individual or entity that has a current provider agreement, is licensed and/or certified to provide services and is enrolled with the Department.
(x) 'Provider agreement.' A written contract between a provider and the Department in which the provider agrees to comply with the provisions of the provider agreement as a condition of receiving Medicaid payment for services provided to recipients.
(y) 'Recipient.' A person who has been determined eligible for Medicaid.
(z) 'Residence.' The place a recipient uses as his or her primary dwelling place and intends to continue to use indefinitely for that purpose.
(aa) 'Service.' A health service or medical supply provided to a recipient.
(bb) '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; Custer, Deadwood, Rapid City and Spearfish, South Dakota; and Ogden and Salt Lake City, Utah.
(cc) 'Service limitations.' Limits on the quantity of covered services which are Medicaid reimbursable as set forth in the rules of the Department.
(cc) 'Usual and customary charge.' The provider's charge to the general public for the similar services.
(a) Payments only to providers. No person or entity that provides services to a recipient shall receive Medicaid funds unless the person or entity has signed a provider agreement and is enrolled.
(b) Enrollment as provider. An individual or entity which wishes to participate in the Medicaid program shall apply on the forms specified by the Division. The Division shall review the application within ten working days after the date it receives the application and all necessary information, including supplemental information requested by the Division. If the application is not approved, the Division shall, in writing, specify the reasons for the decision and advise the applicant of its right to reapply.
(c) Duration of provider agreement. A provider agreement remains in effect until terminated by the provider, terminated pursuant to the rules of the Department or pursuant to the terms of the agreement.
(d) Termination of provider agreement.
(i) A provider which loses its licensure or Medicare certification shall be terminated as a provider effective the same date the provider loses Medicare certification or State licensure. The suspension or termination shall be the same as and shall run contemporaneously with the period of the provider's suspension or termination from Medicare or the period for which it is not licensed; or (ii) A provider may be terminated pursuant to the provider agreement, Chapter XVI or as otherwise provided by law.
(e) Administrative remedies. A provider which is terminated as a Medicaid provider or otherwise sanctioned pursuant to Chapter XVI is entitled to reconsideration and an administrative hearing as set forth in that rule.
(f) Sale of provider.
(i) A provider agreement cannot be transferred at the time a provider is sold except in accordance with applicable Federal law.
(ii) A provider which sells or otherwise transfers ownership or control of his or its practice, or which sells or otherwise transfers ownership or control of an entity which has a provider agreement, shall notify the Department, in writing, of the proposed sale or transfer no later than ninety days before the effective date of the sale or transfer. The failure to give such notice shall result in the termination of the provider agreement.
(a) Nondiscrimination. A provider must comply with Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Americans with Disabilities Act, and all rules promulgated under those Acts.
(b) A provider must not restrict the services it will make available or the persons to whom it will provide services unless such restrictions apply to all persons.
(c) Compliance with federal and State laws. A provider must comply with the Social Security Act, the Wyoming Medical Assistance and Services Act, and all rules promulgated under those Acts.
(d) Compliance with licensing and certification laws. A provider must comply with applicable licensing and certification standards as contained in Wyoming statutes and regulations or the statutes and regulations of the state in which the provider is located, and, where specified, Medicare certification standards.
(a) Services furnished within service area. A service furnished by a provider located outside Wyoming, but within the service area is Medicaid reimbursable if:
(i) The services are furnished in response to an emergency; or
(ii) The provider has entered a provider agreement; and
(A) The service is not available in the recipient's local trade area; and
(B) The out-of-state provider is closer to the recipient's residence than a provider of comparable services within Wyoming.
(b) Services furnished outside the service area. A service furnished by a provider located outside the service area is not Medicaid reimbursable unless:
(i) The service is furnished in response to an emergency;
(ii) The recipient is outside the service area and the recipient's health would be endangered if he were required to return to the service area;
(iii) The recipient is referred to a provider outside the service area when prior authorized and comparable services are not available within the service area; or
(iv) The recipient is less than 19 years of age; and
(A) Is a foster child not covered by Title IV-E of the Social Security Act and resides with a foster family out of state; or
(B) Has been placed in an out-of-state institution.
(c) Retroactive enrollment. An individual or entity which furnishes services to a recipient prior to enrolling as a provider may enroll as a provider and receive Medicaid reimbursement for such services if the services are otherwise reimbursable pursuant to the rules of the Department
(a) Retention. A provider shall maintain medical and financial records, including information regarding dates of services, diagnoses, services furnished, and bills for services, for at least six years after the end of the federal fiscal year (September 30) in which the services were rendered. If an audit is in progress, the records must be maintained until the audit and any subsequent administrative or legal proceedings are resolved. Such records must be maintained for three years in hard-copy, after which they may be maintained on micro-fiche or micro-film.
(b) Availability of records. A provider shall make financial or medical records available upon request to representatives of the Department, the United States Department of Health and Human Services, HCFA, the Wyoming Attorney General or the Wyoming Auditor.
(c) Refusal to produce or maintain records. The refusal of a provider to make financial or medical records available and accessible shall result in the immediate suspension of all Medicaid payments to the provider and all Medicaid payments made to the provider during the record retention period for which records supporting such payments are not produced shall be repaid to the Department within ten days after written request for such repayment, and the Department shall suspend all Medicaid payments for services furnished after such date. Reimbursement shall not be reinstated until the Department determines that adequate records have been produced or are being maintained.
(d) Copying records. The Department may copy records pursuant to Chapter XVI, Section 5(d).
(a) Medicaid Identification Cards. The Department of Family Services issues Medicaid identification cards to recipients. Such cards are valid only for the month and year shown on the card.
(b) An individual that seeks services and does not have a valid Medicaid identification card is responsible for all charges for such services unless the provider receives written verification of eligibility from the Department or local agency before providing services. If a provider receives payment from an individual that is later determined to be eligible for Medicaid, the provider must refund any such payment to the individual before seeking Medicaid reimbursement.
(c) Failure to notify provider of eligibility. If a provider furnishes services to an individual who fails to notify the provider that he or she is a recipient, the provider may submit a claim to Medicaid or seek reimbursement or payment from the recipient. A provider which elects to seek Medicaid reimbursement must accept such payment as payment in full.
(d) Retroactive eligibility. A provider that furnishes services to an individual that becomes a recipient after the date of services may submit a claim to Medicaid seeking Medicaid reimbursement for services furnished during the period the individual was eligible for Medicaid. The provider may receive reimbursement as provided by the rules of the Department.
(a) Procedures. A provider seeking reimbursement for services that require prior authorization as specified in the rules of the Department must:
(i) Submission of information. The provider shall submit a written request to the Department, on the forms specified by the Department, requesting prior authorization before providing services. The Department may request additional information as necessary to review the request.
(ii) Criteria for review. Prior authorization shall be granted if the proposed services:
(A) Are covered services;
(B) Are consistent with the recipient's diagnosis;
(C) Are medically necessary; and
(D) Meet the criteria of the Department's rules.
(iii) Denial of prior authorization.
(A) If a request for prior authorization is denied, the provider may submit a revised request for prior authorization or additional documentation as necessary for the Department to reconsider the matter; or
(B) The recipient may request reconsideration of the denial of prior authorization pursuant to Chapter I.
(C) The denial of prior authorization precludes Medicaid reimbursement for the services in question.
(iv) Failure to timely request prior authorization. The failure to obtain prior authorization before providing services precludes Medicaid reimbursement for such services
(v) Effect of prior authorization. Granting prior authorization shall constitute approval for the provider to receive Medicaid reimbursement for the approved services to be furnished, subject to the other requirements of this rule and post payment review. Prior authorization is not a guarantee of the recipient's eligibility.
(a) Except as otherwise specified in this Chapter or the other rules of the Department, the Medicaid allowable payment shall not exceed the lower of the provider's usual and customary charges and the Medicaid fee schedule in effect on the date services were provided. The fee schedule is available upon request from the Division.
(b) Adjustment to Medicaid fee schedule. The Division shall review the Medicaid fee schedule biannually. The Medicaid fee schedule may be adjusted when necessary to:
(i) Enlist enough providers so that services are available to recipients to the extent that those services are available to the general population; and
(ii) Ensure that payments are consistent with efficiency, economy and quality of care.
(c) Laboratory fees. The Department shall review laboratory fees annually and adjust the fees as necessary to ensure that the Medicaid payment does not exceed Medicare allowable payment for clinical laboratory procedures.
(d) Fees for services not on Medicaid fee schedule. Covered services or procedures which are not on the Medicaid fee schedule described in subsection (a) shall be reimbursed as follows:
(i) The Division shall develop a Medicaid fee by establishing a relationship between the procedure and other covered procedures for which fees have been established, taking into account the following factors involved in the procedure:
(A) Time;
(B) Risk;
(C) Degree of difficulty;
(D) Out-of-pocket expense;
(E) Other provider's usual and customary charges; and
(F) Such other factors as the Division determines are relevant.
(ii) In the event sufficient information is not available to the Division to develop a Medicaid fee, the provider shall be reimbursed seventy percent of the provider's usual and customary charge until sufficient information has been accumulated to determine an allowable fee pursuant to paragraph (i).
(a) Payer of last resort. Medicaid is the payer of last resort. A provider may not seek Medicaid payment for services furnished to a recipient until payment from third parties has been sought pursuant to Chapter IV.
(b) Payment in full of covered services. If the service is a covered service, a provider may not request, receive or attempt to collect any payment from the recipient for the service. The provider must accept the Medicaid allowable payment as payment in full for the services. This subsection does not apply to services provided in excess of service limitations.
(c) Payment for noncovered services. A provider that provides a noncovered service to a recipient may seek payment from the recipient if the provider informed the recipient of the recipient's potential liability before providing the service, and the recipient agreed in writing to pay for such services before they were furnished.
(d) Payment for services that exceed service limitations. A provider that provides a covered service to a recipient that is in excess of service limitations may seek payment from the recipient without complying with subsection (c).
(e) Copayment. A provider may seek copayment from recipients as permitted by the rules of the Department. The amount of the authorized copayment shall be automatically deducted by the Department from the Medicaid allowable payment. Collection of copayment is the sole responsibility of the provider.
(f) Submission of claims.
(i) Claims must be submitted to the Department in the manner and on the forms specified by the Department, must include documentation of prior authorization, if necessary, and such other documentation or records as the Department may request.
(ii) Except as specified below, claims must be submitted to and finalized on or before twelve months after the date of service or the date of discharge, whichever is later.
(A) Medicare cross-over claims must be submitted within six months after the date Medicare acts on the claim; and
(B) In the event of retroactive eligibility, claims must be submitted within six months of the date of the determination of retroactive eligibility.
(C) The date of submission is the date the claim is received by the Department.
(D) Claims not timely submitted shall be rejected.
(iii) A provider shall not bill the Department in excess of the provider's usual and customary charge for the service.
(iv) A provider may seek Medicaid payment through a business agent for services furnished to a recipient if the business agent's compensation is related to the actual cost of processing the billing and is not related on a percentage or other basis to the amount of the claim and is not dependent upon payment of the claim.
(v) A provider is responsible for all claims, whether submitted directly or through an agent, designee, employee or other intermediary.
(vi) Any loss of Medicaid reimbursement caused by provider error is the responsibility of the provider and the provider may not bill the recipient for such services.
(a) Notice of excess payments. After determining that a provider has received excess payments, the Department shall send written notice to the provider stating the amount of the excess payments, the basis for the determination of excess payments and the provider's rights to request reconsideration of that determination pursuant to Section 13.
(b) Reimbursement of excess payments. Except as otherwise specified by the rules of the Department, a provider must reimburse the Department for excess payments within 30 days after the provider receives written notice from the Department of the excess payments, even if the provider has requested reconsideration or an administrative hearing regarding the determination of excess payments.
(c) Methods of recovery of excess payments. If a provider does not timely reimburse the Department, the Department may recover the excess payments, even if the provider has requested reconsideration or an administrative hearing regarding the determination of excess payments, by:
(i) Withholding all or part of Medicaid payments until the excess payments are recovered;
(ii) Initiating a civil lawsuit against the provider; or
(iii) Any other method of collecting a debt or obligation permitted by law.
Section 13. Reconsideration.
(a) Request for reconsideration. A provider may request that the Department reconsider any decision to recover excess payments. Such request must be mailed to the Department by certified mail within twenty days after the date the provider receives notice pursuant to Section 14.
(b) Reconsideration. The Department shall review the decision and send written notice to the provider of its final decision within forty-five days after receipt of the request for reconsideration. The Department may request additional information from the provider as part of the reconsideration process.
(c) Administrative hearing. A provider may request an administrative hearing regarding the final decision pursuant to Chapter 1 by mailing by certified mail or personally delivering a request for hearing to the Department within twenty days after the date the provider receives notice of the final decision. The request for hearing must meet the requirements of Chapter I.
(d) Failure to request reconsideration. A provider that fails to request reconsideration pursuant to this section may not subsequently request an administrative hearing regarding the recovery of excess payments pursuant to Chapter I.
Section 14. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.
STATEMENT OF REASONS
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 a rules.
The Health Care Financing Administration of the United States Department of Health and Human Services (HCFA) is the federal agency for administering the Medicaid program.
The Act and HCFA regulations require the Department to establish conditions of participation for those providers of medical services that wish to receive Medicaid funds for such services furnished to Medicaid recipients. The Department is also authorized to establish procedures to be followed by providers in submitting claims seeking payment of Medicaid funds.
The Department is promulgating this rule to establish the conditions of participation for providers of medical services to Medicaid recipients. The rule also establishes the procedures which providers must follow in submitting claims to the Department seeking payment of Medicaid funds.
This rule is being promulgated to replace the existing Chapter III, which was promulgated as an emergency rule. This rule is to be read in conjunction with Chapter XXVI, Covered Services, which is being promulgated contemporaneously to implement certain changes which became effective March 1, 1992.