Wyo. Code R. 048-0037-44
Medicaid
Chapter 44: Environmental Modifications & Specialized Equipment for Home & Community Based Waiver Services
Effective Date: 12/29/2006 to 06/21/2017
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.44.12292006
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.
(a) This Chapter shall apply to and govern Medicaid reimbursement of environmental modification services and specialized equipment services provided under the Wyoming Medicaid Adult Developmental Disabilities Home and Community Based Waiver, the Wyoming Children's Developmental Disabilities Home and Community Based Waiver, and the Wyoming Acquired Brain Injury Home and Community Based Waiver on or after June 1, 2006.
(b) The provisions contained in this Chapter shall be subordinate to the provisions in the Wyoming Medicaid Adult Developmental Disabilities Home and Community Based Waiver, the Wyoming Medicaid Children's Developmental Disabilities Home and Community Based Waiver, and the Wyoming Medicaid Acquired Brain Injury Home and Community Based Waiver submitted to the Centers for Medicare and Medicaid Services pursuant to Section 1915(c) of the Social Security Act codified as 42 U.S.C. § 1396n.
(c) The Division 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 Chapter is the standard terminology and has the standard meaning used in accounting, health care, Medicaid, and Medicare.
(b) Methodology. This Chapter establishes standards for environmental modification services and specialized equipment services provided through Developmental Disabilities Division Home and Community Based Waivers.
(c) This Chapter is intended to be read in conjunction with the Wyoming Medicaid Adult Developmental Disabilities Home and Community Based Waiver, the Children's Developmental Disabilities Home and Community Based Waiver, and the
Acquired Brain Injury Home and Community Based Waiver, submitted to Centers for Medicare and Medicaid Services pursuant to Section 1915(c) of the Social Security Act, Chapter 41, Chapter 42 and Chapter 43 of the Medicaid Rules, and Chapter 1, Rules for Individually-selected Service Coordinators of the Rules of the Developmental Disabilities Division.
(d) Unless otherwise specified, 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 this Chapter, including any applicable amendments, corrections, or revisions, but excluding any subsequent amendments or changes.
The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indications 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.
“Acquired brain injury.” Acquired brain injury as defined in Chapter 43.
(b) “Acquired Brain Injury Home and Community Based Waiver.” The Acquired Brain Injury Home and Community Based Waiver submitted to and approved by the Centers for Medicare and Medicaid Services pursuant to Section 1915(c) of the Social Security Act.
(c) “Adult.” A person twenty-one years of age or older for purposes of the Adult Developmental Disabilities Home and Community Based Waiver. Participants between the ages of 18 and 21 receive services on the Children’s Developmental Disabilities Home and Community Based Waiver but are considered an adult in the State of Wyoming.
(d) “Adult Developmental Disabilities Home and Community Based Waiver.” The Adult Developmental Disabilities Home and Community Based Waiver submitted to and approved by the Centers for Medicare and Medicaid Services pursuant to Section 1915(c) of the Social Security Act.
(e) “Advocate.” A person, chosen by the participant or legal guardian, who supports and represents the rights and interests of the participant in order to ensure the participant’s full legal rights and access to services. The advocate can be a friend, a relative, or any other interested person. An advocate has no legal authority to make decisions on behalf of a participant.
(f) “Case Management.” Covered service on the Adult Developmental Disabilities Home and Community Based Waiver, the Children’s Developmental Disabilities Home and Community Based Waiver, and the Acquired Brain Injury Home and Community Based Waiver, as defined in Chapter 41, Chapter 42, and Chapter 43.
(g) “Centers for Medicare and Medicaid Services (CMS).” The Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services, its agent, designee, or successor.
“Chapter 1.” Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
“Chapter 3.” Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
“Chapter 16.” Chapter 16, Medicaid Program Integrity, of the Wyoming Medicaid Rules.
“Chapter 26.” Chapter 26, Medicaid Covered Services, of the Wyoming Medicaid Rules.
“Chapter 35.” Chapter 35, Medicaid Benefit Recovery, of the Wyoming Medicaid Rules.
“Chapter 39.” Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid Rules.
“Chapter 41.” Chapter 41, DD Adult Waiver Services, of the Wyoming Medicaid Rules.
“Chapter 42.” Chapter 42, DD Child Waiver Services, of the Wyoming Medicaid Rules.
“Chapter 43.” Chapter 43, Acquired Brain Injury Waiver Services, of the Wyoming Medicaid Rules.
“Chapter 45.” Chapter 45, Waiver Provider Certification and Sanctions, of the Wyoming Medicaid Rules.
(r) “Child.” A person under 21 years of age for participants receiving services on the Children’s Developmental Disabilities Home and Community Based Waiver. Participants between the ages of 18 and 21 receive services on the Children’s Developmental Disabilities Home and Community Based Waiver but are considered an adult in the State of Wyoming and shall sign their own documents unless they have a legal guardian.
(s) “Children’s Developmental Disabilities Home and Community Based Waiver.” The Children’s Developmental Disabilities Home and Community Based Waiver submitted to and approved by the Centers for Medicare and Medicaid Services pursuant to Section 1915(c) of the Social Security Act.
“Claim.” A request by a provider for Medicaid payment for covered services provided to a participant.
(u) “Covered services.” Those services that are Medicaid reimbursable pursuant to Chapter 41, Chapter 42, and Chapter 43.
“Department.” The Wyoming Department of Health, its agent, designee, or successor.
“Developmental disability.” Developmental disability as defined in Chapter 41 and Chapter 42.
“Director.” The Director of the Department or the Director’s agent, designee, or successor.
“Division.” The Developmental Disabilities Division of the Department, its agent, designee, or successor.
“Enrolled.” Enrolled as defined in Chapter 3.
(aa) “Environmental modification.” Covered service on the Adult Developmental Disabilities Home and Community Based Waiver, the Acquired Brain Injury Home and Community Based Waiver, and the Children’s Developmental Disabilities Home and Community Based Waiver. The physical modification of a residence of a participant, pursuant to this Chapter.
(bb) “EPSDT.” Early and periodic screening, diagnosis, and treatment services for participants under the age of 21 pursuant to Chapter 6 of the Wyoming Medicaid Rules, Health Check.
“Excess payments.” Excess payments as defined in Chapter 39.
(dd) “Extraordinary Care Committee (ECC).” A committee that has the authority to approve or deny individual plans of care, emergency funding, and funding due to a material change in circumstance or other condition justifying an increase in funding as defined in Chapter 41, Chapter 42, and Chapter 43.
(ee) “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 the information contained in the facility’s cost reports or a claim.
“Functionally necessary.” A waiver service that is:
(i) Required due to the diagnosis or condition of the participant, and
(ii) Recognized as a prevailing standard or current practice among the provider’s peer group, or
(iii) Intended to make a reasonable accommodation for functional limitations of a participant, to increase a participant’s independence, or both.
(iv) Provided in the most efficient manner and/or setting consistent with appropriate care required by the participant's condition.
(v) For the purposes stated, utilization is not experimental or investigational and is generally accepted by the medical community.
(gg) 'Funding.' That combination of federal and state funds available to pay for covered services. Funding does not include any other funds available to the Department that are not designated for covered services.
(hh) 'Generally Accepted Auditing Standards (GAAS).' Current auditing standards, practices, and procedures established by the American Institute of Certified Public Accountants.
(ii) 'Guardian.' A person lawfully appointed by the courts to act on the behalf of the participant or applicant.
(jj) 'Health and Human Services (HHS).' The United States Department of Health and Human Services, its agent, designee, or successor.
(kk) 'ICF/MR.' An intermediate care facility for people with mental retardation as defined in 42 U.S.C. § 1396d(d), which is incorporated by this reference.
(ll) 'Individualized Budget Amount (IBA).' The Division's allocation of Medicaid waiver funds that may be available to a participant to meet his or her needs pursuant to Chapter 41, Chapter 42, and Chapter 43.
(mm) 'Individual Plan of Care (IPC).' Individual Plan of Care as defined in Chapter 41, Chapter 42, and Chapter 43.
(nn) 'Individual Plan of Care (IPC) team.' Individual Plan of Care team as defined in Chapter 41, Chapter 42, and Chapter 43.
(oo) 'Individually-selected Service Coordinator (ISC).' Individually-selected service coordinator as defined in Chapter 41, Chapter 42, and Chapter 43.
(pp) 'Institution.' An Intermediate Care Facility for people with Mental Retardation (ICF/MR), nursing facility, hospital, prison, or jail.
(qq) '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.
(rr) 'Medicaid allowable payment.' Medicaid reimbursement for covered services as determined pursuant to this Chapter.
(ss) 'Medicaid Fraud Control Unit (MFCU).' The Medicaid Fraud Control Unit of the Wyoming Attorney General's Office, its agent, designee, or successor.
(tt) “Medical records.” All documents, in whatever form, in the possession of or subject to the control of a provider, which describe the participant’s diagnosis, condition or treatment, including, but not limited to, the individual plan of care.
(uu) “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 services must be:
(i) Consistent with the diagnosis and treatment of the participant’s condition.
(ii) Recognized as the prevailing standard or current practice among the provider’s peer group.
(iii) Required to meet the medical needs of the participant and undertaken for reasons other than the convenience of the participant and the provider, and
(iv) Provided in the most efficient manner and/or setting consistent with appropriate care required by the participant’s condition.
“Medicare.” The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(ww) “Mental retardation.” A diagnosis as determined by a psychologist per the American Association on Mental Deficiency, Classification in Mental Retardation (Herbert J. Grossman ed., 8th ed. 1983).
(xx) “Modification to individual plan of care.” A change to an individual plan of care. A modification may include the addition, substitution, or deletion of providers, covered services, or both. Modifications may increase or decrease the Medicaid waiver allowable payment.
“Overpayments.” Overpayments as defined in Chapter 39.
“Participant.” An individual who has been determined eligible for covered services on a Waiver.
(aaa) “Physician.” A person licensed to practice medicine or osteopathy by the Wyoming Board of Medical Examiners or a similar agency in a different state.
“Prior authorization.” Prior authorization as defined in Chapter 3.
“Provider.” A person or entity that is certified by the Division to furnish covered services and is currently enrolled as a Medicaid Waiver provider.
(ddd) “Related condition.” A condition that results in a severe, chronic disability affecting an individual which manifests before he or she reaches age twenty-two and that is attributable to cerebral palsy, seizure disorder, or any condition other than mental illness that is closely related to mental retardation and that requires similar services, as determined by a licensed psychologist or physician.
“Services.” Medical, habilitation, or other services, equipment, or supplies, appropriate to meet the needs of a participant.
(fff) “Specialized equipment” New or used devices, controls, or appliances that enable a participant to increase his or her ability to perform the activities of daily living or to perceive, control, or communicate with the environment.
“Third-party liability.” Third-party liability pursuant to Chapter 35.
(a) All persons possess inalienable rights under the Constitutions of the United States and the State of Wyoming. Persons with developmental disabilities also possess the rights outlined in the Developmental Disabilities Assistance and Bill of Rights Act of 2000, 42 U.S.C. § 15001, and which are included as Appendix A to this Chapter.
(b) It is the philosophy of the Division to develop reasonable and enforceable rules for the provision of services to individuals with developmental disabilities in community settings in lieu of unnecessary institutionalization. This philosophy is mandated in the Supreme Court ruling on Olmstead v. L.C ex rel. Zimring, 527 U.S. 581 (1999).
(c) This Chapter is designed not only to support the philosophy of community-based services but to also protect the health, welfare, and safety of participants.
(a) Environmental modifications requests shall meet at least two of the following criteria for approval by the Division:
(i) Be functionally necessary, and
(ii) Contribute to a person’s ability to remain in or return to his or her home and out of an ICF/MR setting, or
(iii) Be necessary to ensure the person’s health, welfare, and safety.
(b) Environmental modifications may include but are not limited to:
(i) The installation of ramps.
(ii) The installation of grab-bars.
(iii) Widening of doorways.
(iv) Modification of a bathroom.
(A) Modification of a bathroom that adds square feet to the home shall be covered only if it is the most cost effective modification that meets the needs of the participant.
(v) Installation of specialized electric or plumbing systems necessary to accommodate necessary specialized equipment or supplies.
(vi) Modifications that address accessibility limitations.
(vii) Modifications that address fire code requirements.
(viii) Fences for health or safety concerns.
(A) Fences shall not take the place of required supervision of the participant.
(B) Coverage of fences shall not exceed 200 linear feet.
(c) Environmental modifications shall not include:
(i) Modifications to a residence that are of general utility or are primarily for the convenience of persons other than the participant, such as caregivers or family members and are not of direct medical or functional benefit to the participant.
(ii) Installation or replacement of carpeting.
(iii) Roof repair or replacement.
(iv) Central air conditioning.
(v) New carports, porches, patios, garages, porticos or decks or repairing such structures.
(vi) Pools, spas, hot tubs or modifications to install pools, spas or hot tubs;
(vii) Landscaping or yard work, landscaping supplies, pest exterminations or removal of yard items.
(viii) Modifications that are part of new construction costs.
(ix) Modifications that add to the square footage of the home except bathroom modifications as specified in (b)(iv) of this section.
(x) Window replacements.
(xi) Repairs or replacement of structural building components.
(xii) Modifications to a residence when the cost of such modifications exceeds the value of the residence before the modification.
(d) Covered modifications of rented or leased homes shall be those extraordinary alterations that are uniquely needed by the individual and for which the property owner would not ordinarily be responsible.
(i) Such modifications shall require written approval from the homeowner or landlord.
(ii) Modifications shall include the minimum necessary to meet the functional requirements of the participant.
(e) The homeowner shall be responsible for general maintenance of environmental modifications.
(f) Sale of environmental modifications shall not profit the participant or family.
(a) The individual plan of care team shall review the need for environmental modifications during the six month or annual individual plan of care meeting. Environmental modifications requests submitted at other times during the individual plan of care year may be reviewed if significant health, safety, or access concerns are identified.
(b) When the individual plan of care team identifies an environmental concern or need, the individually selected service coordinator shall submit the following information to the Division:
(i) A description of the environmental concern or need.
(ii) How the environmental concern is related to the participant's diagnosed disability.
(iii) How addressing the environmental concern will:
(A) Contribute to the participant's ability to remain in or return to his or her home.
(B) Increase the participant's independence.
(C) Address the participant's accessibility concerns.
(D) Address health and safety needs of the participant.
(c) The Division may schedule an on-site assessment of the environmental concern including an evaluation of functional necessity with appropriate professionals under contract with the Division or instruct the ISC to proceed to section (d).
(i) The assessment shall include:
(A) A statement verifying that the request meets at least two of the criteria pursuant to Section (6)(a) of this Chapter.
(B) A description of the modification that will address the environmental concern, including the minimum quality and quantity of materials needed, and estimated cost range for modification.
(d) The individually-selected service coordinator shall work with the participant or guardian to identify two certified environmental modification providers and contact the providers to obtain quotes. Quotes shall include:
(i) A detailed description of the work to be completed, including drawings or pictures when appropriate.
(ii) Estimate of the material and labor needed to complete the job, including costs of clean up.
(iii) Estimate for building permit, if needed.
(iv) Estimated timeline for completing the job.
(v) Name, address, and telephone number of the provider.
(vi) Signature of the provider.
(e) The individually-selected service coordinator shall submit the pre-approval section of the individual plan of care to the Division, including:
(i) The assessment completed by the professional team or the written approval from the Division to proceed with quotes.
(ii) Two quotes completed by certified environmental modification providers.
(A) If two quotes cannot be obtained, an explanation as to why only one quote was submitted.
(f) The Division shall notify the individually-selected service coordinator of the approval, including the quote that was approved.
(i) Modifications shall be completed by the date stated in the individual plan of care unless otherwise authorized by the Division.
(ii) If the cost of a modification increases due to a significant change in costs of material, the individually-selected service coordinator shall submit a revised quote detailing the change in cost.
(g) Upon completion of the environmental modification the provider shall have the homeowner sign the original quote verifying that the modification is complete.
(i) The environmental modification provider shall submit the signed quote to the participant's individually-selected service coordinator.
(ii) If the homeowner has concerns with the modification they shall contact the individually-selected service coordinator, who shall inform the Division of the concerns.
(A) The Division shall complete an on-site review of the modification to determine if is completed as described in the original quote.
(h) The Division or its agent may conduct on-site visits or any other investigations deemed necessary prior to approving or denying the request for an environmental modification.
(i) The Division reserves the right to deny requests for environmental modifications that are not within usual and customary charges or industry standards.
(a) Specialized equipment shall meet at least three of the following criteria:
(i) Be functionally necessary, and
(ii) Be necessary to increase ability to perform activities of daily living or to perceive, control, or communicate with the environment in which the person lives, or
(iii) Be necessary to enable the participant to function with greater independence and without which the person would require institutionalization, or
(iv) Be necessary to ensure the person's health, welfare, and safety.
(b) The individual plan of care shall reflect the need for equipment, how the equipment addresses health and safety needs of the participant or allows them to function with greater independence, and specific information on how often the equipment is used and where it is used.
(c) Specialized equipment may include but is not limited to:
(i) Lifts.
(ii) Communication devices, including computers for communication when there is substantial documentation that a computer will meet the needs of the person more appropriately than a communication board.
(iii) Computer adaptations and software used for skill building.
(iv) Adaptations of items of general use that are specifically required to accommodate the participant's diagnosed disability.
(v) Items that are normally available through public resources but that are not available to the participant due to geographic constraints and that are necessary to address specific health needs, such as exercise equipment.
(vi) Games or items that are specifically for skill building and related to the participant's diagnosed disability.
(A) The individual plan of care limit shall be $500 per plan year for items.
(vii) One car seat for participants age 9 years or older.
(A) Requests for car seats with specialized seating or positioning for a participant of any age shall be reviewed for functional necessity.
(viii) One additional mobility item such as a wheelchair or stroller every 3 years that is not covered under the Wyoming Medicaid state plan.
(ix) One pair of eye glasses every 3 years for adult participants.
(d) Specialized equipment shall not include the following, even if prescribed by a licensed health care professional:
(i) Items paid for under the Medicaid state plan or under EPSDT.
(ii) Educational or therapy items that are an extension of services provided by the Department of Education.
(iii) Items of general use that are not specific to a disability, or that would normally be available to any child or adult, including but not limited to furniture, recliners, desks, shelving, appliances, bedding, and bean bag chairs, crayons, coloring books, other books, games, toys, videotapes, CD players, radios, cassette players, tape recorders, television, VCRs, DVD players, electronic games, cameras, film, swing sets, other indoor and outdoor play equipment, trampolines, strollers, play houses, bike helmets, bike trailers, trampolines, bicycles, health club memberships, merry-go-rounds, golf carts, four wheelers, go-carts, scooters, and motor homes.
(iv) Pools, spas, hot tubs or modifications to install pools, spas, or hot tubs.
(v) Computers and computer equipment, including the CPU, hard drive, and printers, except for situations pursuant to(c)(ii) of this Section.
(vi) Items that are not proven interventions through either professional peer reviews or evidence based studies.
(vii) Communication items such as telephones, pagers, pre-paid minute cards and monthly services.
(e) Repairs shall be completed by the manufacturer if a warranty is in place.
(f) Requests for repairs not covered by warranty shall be submitted to the Division for approval.
(g) Sale of specialized equipment shall not profit the participant or family.
(h) Participants, families, and/or guardians are encouraged to share equipment that is no longer in use with an equipment lending library such as the Weston Center at the Wyoming State Training School.
(a) The team shall review the need for specialized equipment during the six month or annual individual plan of care meeting. Specialized equipment requests submitted at other times during the individual plan of care year may be reviewed if significant health, safety, or access concerns are identified.
(b) Approval for specialized equipment shall require:
(i) A recommendation from a therapist or professional with expertise in the area of need. The recommendation shall include:
(A) Description of the functional need for the specialized equipment.
(B) How the specialized equipment will contribute to a person's ability to remain in or return to his or her home and out of an ICF/MR setting.
(C) How the specialized equipment will increase the individual's independence and decrease the need for other services.
(D) How the specialized equipment addresses accessibility, health, and/or safety needs of the participant.
(E) Documentation that the participant has the capability to use the equipment.
(F) Documentation that the waiver is the payer of last resort;
(G) A description of how equipment shall be delivered and who will train the person and providers on the equipment.
(H) Documentation of an estimate of a quote of the equipment, including a maximum mark up on the equipment of 20%.
(I) The quote may include a detailed description of the need and costs for expert assembly of the equipment in addition to 20% markup.
(II) The quotes may include a detailed description of the need and cost for training on the specialized equipment in addition to the 20% mark up.
(ii) The Division may schedule a review of the specialized equipment quote, including an evaluation of functional necessity, with appropriate professionals under contract with the Division.
(iii) The review shall include a statement verifying that the request meets at least three of the criteria pursuant to Section 8(a) of this Chapter.
(c) The Division may request documentation that a less expensive, comparable alternative to requested equipment or supplies is not available or practical. If a more cost-effective alternative is determined to be available, the Department shall deny the original request or specify that only the less costly equipment or supplies are approved.
(a) Payments only to providers. No person or entity that furnishes covered services to a participant shall receive Medicaid funds unless the person or entity has signed a provider agreement, is enrolled, and is certified by the Division as a provider at the time of service delivery.
(b) Compliance with Chapter 3, Provider Participation, of the Wyoming Medicaid Rules. A provider that wishes to receive Medicaid reimbursement for services furnished to a participant shall meet the provider participation requirements of Chapter 3, Provider Participation, of the Wyoming Medicaid Rules, Sections 4 through 6, which are incorporated by this reference.
(c) Compliance with Chapter 45, Provider Certification and Sanctions, of the Wyoming Medicaid Rules. A provider that wishes to provide Waiver services shall also meet the applicable criteria for Division certification set forth in Chapter 45, which is incorporated by this reference.
(a) A provider shall comply with Chapter 3, Provider Participation, of the Wyoming Medicaid Rules, Section 7, which is incorporated by this reference.
(b) Individually-selected service coordinators shall maintain copies of documentation from other providers for a twelve month period.
Section 12. Verification of Participant Data A provider shall comply with Chapter 3, Section 8, which is incorporated by this reference.
Section 13. Medicaid Waiver Allowable Payment Medicaid payment under this Chapter shall not exceed the provider's usual and customary charge for like or similar services to non-waiver clients.
Section 14. Third-party Liability.
(a) Submission of claims. Claims for which third-party liability exists shall be submitted in accordance with Chapter 35.
(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 15. Submission and Payment of Claims. The submission and payment of claims shall be pursuant to the provisions of Chapter 3.
Section 16. Recovery of Excess Payments or Overpayments.
(a) The Department may recover excess payments pursuant to Chapter 39.
(b) The Department may recover overpayments pursuant to Chapter 16.
Section 17. Audits.
(a) The Division or the Centers for Medicare and Medicaid Services may audit a provider's financial records, medical records, or employment records, at any time to determine whether the provider has received excess payments or overpayments.
(b) The Division or the Centers for Medicare and Medicaid Services may perform audits through employees, agents, or through a third party. Audits shall be performed in accordance with generally accepted auditing standards.
(c) Disallowance. The Division shall recover excess payments or overpayments pursuant to Section 16 of this Chapter.
(d) 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.
(e) The Division shall share the results of the audit with the provider before excess payments or overpayments are recovered. However, nothing in this section shall abrogate the rights of the State to recover excess payments or overpayments in accordance with Chapter 16 or Chapter 39.
Section 18. Reconsideration. 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, Chapter 16, or Chapter 39 as applicable.
Section 19. Disposition of Recovered Funds. The Department shall dispose of recovered funds pursuant to the provisions of Chapter 16.
Section 20. 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 its various provisions.
Section 21. Superseding Effect. This Chapter supersedes all prior rules or policy statements issued by the Division, including Provider Manuals and Provider Bulletins, which are inconsistent with this Chapter, except Chapter 1, Rules for Individually-selected Service Coordinators of the Rules of the Developmental Disabilities Division which remain in effect.
Section 22. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in full force and effect.