Wyo. Code R. 048-0037-4
Medicaid
Chapter 4: Third Party Liability
Effective Date: 06/28/1995 to 10/27/1995
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.4.06281995
This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Service Act of 1967, as amended (W.S. § 42-4-101 et seq.) and the Wyoming Administrative Procedures Act, as amended (W.S. § 16-3-101 et seq.).
(a) This Chapter and Chapter 35 shall apply to and govern all issues of third party liability and Medicaid benefit recovery.
(b) The Department may issue Manuals or Bulletins to providers and/or other affected third parties to interpret the provisions of this Chapter. Such Manuals or 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 this Chapter.
(a) This Chapter is intended to implement and be read in conjunction with the third party liability requirements of the Social Security Act and HCFA regulations, and the provisions of Chapter 35.
(b) 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.
(a) 'Administrator.' The administrator of the division, the administrator's agent, designee or successor.
(b) 'Applicant.' A person who has submitted a written application for Medicaid, either directly or through a representative acting on his or her behalf, which has not received final action.
(c) 'Application.' An applicant's written request for Medicaid.
(d) 'Assignment of benefits.' The transfer from an applicant or recipient to the
Department of the applicant's or recipient's rights to medical support or payments for services from any third party payer.
(e) 'Chapter I.' Chapter I, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.
(f) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(g) 'Chapter 35.' Chapter 35, Medicaid Benefit and Estate Recoveries, of the Wyoming Medicaid Rules.
(h) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(i) 'Division.' The Division of Health Care Financing of the Department, its agent, designee or successor.
(j) 'HHS.' The United States Department of Health and Human Services.
(k) 'Local agency.' The county field office of the Wyoming Department of Family Services, its agent, designee or successor.
(l) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act, as amended, and the Wyoming Medical Assistance and Services Act, as amended.
(m) 'Medicaid benefit recovery.' The recovery by the Department, pursuant to Chapter 35, from a recipient or a third party payer of Medicaid payments made to or on behalf of a recipient.
(n) 'Medicaid claim.' A request by a provider for Medicaid payment for services provided to a recipient.
(o) 'Medicare.' The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(p) 'Medicare crossover claim.' A claim for services provided to a recipient who is eligible for Medicare and Medicaid.
(q) 'Provider.' A provider as defined by Chapter 3, which definition is incorporated by this reference.
(r) 'Recipient.' A person who has been determined eligible for Medicaid or a person formerly eligible for Medicaid on whose behalf the Medicaid program has made or is obligated to make payments of Medicaid funds.
(s) 'Services.' Goods or services authorized for Medicaid payments under W.S. § 42-4-103 and the rules of the Department.
(t) 'Subrogation.' The succession of the Department to the rights of a recipient with respect to third party payers.
(u) 'Third party liability.' The right of a recipient to recover part or all of the costs of services from a third party payer.
(w) 'Third party payer.' A person, entity, agency, or government program that may be liable to pay, or that pays all or part of the costs of services provided to a recipient. 'Third party payer' includes, but is not limited to, Medicare, insurance companies, workers' compensation, defendants or potential defendants in legal actions involving recipients or an individual or entity acting on behalf of a recipient, or a spouse or parent who is obligated by law or court order to pay all or part of such costs. 'Third party payer' also includes an individual or entity liable pursuant to this Chapter and/or Chapter 35.
(x) 'TPL waiver.' A waiver granted by HCFA of the third party liability requirements of this Chapter.
(i) Automatic assignment of benefits. By signing an application, an applicant makes an assignment of benefits to the Department of benefits on the applicant's behalf and on behalf of any relative for whom application is made.
(ii) Effective dates of assignment of benefits. The assignment of benefits is effective upon a determination of eligibility and includes any period of retroactive eligibility. It remains in effect for all services furnished to the recipient during the recipient's period of Medicaid eligibility.
(b) Payer of last resort. Medicaid will pay for services only after all sources of third party liability have been exhausted, except as provided by 42 U.S.C. § 1396d(b) and Title V of the Social Security Act.
(c) Recovery of payments from third party payers. The Department may recover from third party payers pursuant to the procedures and standards of applicable federal law and W.S. § 42-4-201 et seq., which are incorporated by this reference.
(d) Extent of recovery. If the Department pays or is or becomes obligated to pay Medicaid funds to or on behalf of a recipient because of an injury, illness or disability for which a third party payer is or becomes liable, the Department may recover the full amount of such Medicaid funds from the third party payer to the extent of such payer's liability to the recipient.
(e) A third party payer making payments to the Department, a recipient or other individual or entity pursuant to this Chapter or Chapter 35 must name the Division as a payee on all checks, drafts, or other methods of payment.
(f) Liability to the Department.
(i) A third party payer which pays a provider, recipient or third party after Medicaid has made payments to or on behalf of the recipient, remains liable to the Department for the such payments up to the amount of Medicaid payments.
(ii) A third party payer which enters a settlement with or on behalf of a recipient remains liable for the state's Medicaid claim unless the state through the attorney general signs the release prior to payment of an agreed settlement.
(iii) A recipient's attorney who fails to comply with this Chapter is potentially liable pursuant to Chapter 35, which is incorporated by this reference.
(g) The recovery or allowance of attorney's fees for an attorney who represents a recipient or the estate of a recipient in a matter involving third party liability shall be pursuant to Chapter 35.
(a) Notice to applicants of assignment of benefits. At the time of application, the Department shall provide written notice to applicants of the automatic assignment of benefits pursuant to W.S. § 42-4-106(b).
(b) Notice to provider of responsibilities.
(i) At the time a provider becomes enrolled in Medicaid, the Department shall give written notice to the provider of the procedures to follow in submitting Medicaid claims which involve or may involve third party payers. Such notice may be given through Provider Manuals or Bulletins.
(ii) Within a reasonable time after the submission of a Medicaid claim for which there may be a third party payer, the Department shall provide written notice to such provider, stating:
(A) The Department's right to recover any payments which have been made or which will be made in the future;
(B) The Department's right to reject any Medicaid claims because of the probable existence of a third party payer; and
(C) The procedures the provider shall follow in submitting Medicaid claims involving third party payers.
(a) Notification of third party payer. An applicant or recipient shall notify the local agency or the Social Security Administration or the Department of the possibility of third party liability at the time of application, at the time of an eligibility redetermination, and within ten days after any change in potential third party payers.
(b) Notice to providers. A recipient shall present his or her eligibility card to a provider at the time the recipient requests services. A recipient shall also inform a provider of the existence or possible existence of a third party payer at the time the recipient requests services from the provider and upon request from the provider.
(c) Cooperation in establishing paternity and obtaining medical support. An applicant or recipient shall cooperate with the Department and local agency in establishing paternity of a child eligible for Medicaid or applying for Medicaid, and identifying and collecting from any third party payer. Cooperation includes:
(i) Appearing at the Department or local agency office to provide information or evidence, under penalty of perjury, regarding paternity;
(ii) Appearing as a witness at a court or other proceeding to testify regarding paternity;
(iii) Paying to the Department any medical support or medical care funds received that are covered by the assignment of benefits; and
(iv) Upon request from the Department or local agency, taking any other reasonable steps to assist in establishing paternity, determining third party liability and securing payment from third party payers.
(d) The refusal to cooperate in establishing paternity as set forth above, or the refusal to cooperate in locating third party payers or recovering payments from such payers, shall render such person ineligible for Medicaid, except as provided in 42 CFR 433.148(b).
(a) Verify and obtain information. At the time a recipient requests services from a provider, the provider shall review the recipient's eligibility card for information regarding third party payers. The provider shall ask the recipient if the information on the card is current and whether there are or may be additional third party payers. If the provider learns of a potential third party payer that is not listed on the eligibility card, the provider shall notify the Department in writing of that information.
(b) Notify Department of requests for information. The provider shall notify the Department in writing of any requests for medical records or information regarding a recipient by the recipient, an attorney, or any other person or entity acting on behalf of the recipient or a third party.
(c) Billing. Unless otherwise provided by a TPL waiver, this subsection shall govern the submission of bills involving third party payers.
(i) Third party payer. When a provider is informed by a recipient, the Department or any other source that the recipient has or may have coverage by a third party payer, the provider shall seek payment from the third party payer before submitting a Medicaid claim. When the amount of third party liability is less than the allowable Medicaid payment, the provider may submit a Medicaid claim for the difference between the allowable Medicaid payment and the amount of third party liability. Such Medicaid claim shall be accompanied by documentation of the amount of third party liability.
(ii) Rejection by third party payer. The provider may submit a Medicaid claim to the Department after receiving a written notice from the third party payer that a request for payment for services has been rejected. In such case, the provider shall attach a copy of the notice of rejection to the Medicaid claim. The Department shall process the Medicaid claim subject to its normal procedures and standards.
(iii) Failure to respond by third party payer. A provider which has not received payment or a rejection notice from a third party payer within ninety days after submitting a request for payment, may submit a Medicaid claim. The provider shall submit with the Medicaid claim a copy of the request for payment to the third party payer, documentation of an additional attempt to contact the third party payer, and any written communication the provider has received from the third party payer. The Department shall process the Medicaid claim subject to its normal procedures and standards.
(iv) Submission of Medicaid claims after payment by third party payer. A provider which has received payment from a third party payer may submit a Medicaid claim. In such cases the provider shall submit with the Medicaid claim documentation of the payment received. The Department shall allow such Medicaid claim only to the extent the allowable Medicaid reimbursement exceeds the payment received from the third party payer and subject to the Department's normal procedures and standards.
(v) Time limit for submission of Medicaid claims. A provider shall submit Medicaid claims to the Department within twelve months of the date of service, regardless of the potential involvement of a third party payer, except that Medicare crossover claims shall be submitted within six months after the date of payment or rejection by Medicare.
Medicaid claims submitted after the time limits specified in this paragraph shall be rejected.
(a) Probable existence of liability of third party payer established at time of Medicaid claim. If the Department has established the probable existence of liability of a third party payer at the time a provider submits a Medicaid claim, the Department shall reject the Medicaid claim and return it to the provider for a determination of the amount of such liability.
(b) Probable existence of liability of third party payer not established at time of Medicaid claim or unavailability of third party payments. If the Department has not established the probable existence of liability of a third party payer at the time a provider submits a Medicaid claim, or if third party payments are not available at the time a provider submits a Medicaid claim, the Department shall process the Medicaid claim in accordance with the Department's normal procedures and standards.
(c) Establishing probable existence of liability of a third party payer. The probable existence of liability of a third party payer is established when the Department receives information from any source confirming the existence and extent of liability of a third party payer. When the amount of liability is established, the Department shall process and pay Medicaid claims involving third party liability only to the extent that the Medicaid payment allowed by the Department's normal procedures and standards exceeds the amount of the third party payer's liability.
(d) Unavailability of third party payments. Third party payments are not available at the time of the submission of a Medicaid claim if the existence and extent of third party payer liability is still disputed.
(e) Timely filing requirements. Providers are subject to the timely filing requirements of Chapter 3, which requirements are incorporated by this reference.
(f) Benefit recovery. Providers are subject to the benefit recovery requirements of Chapter 35, which requirements are incorporated by this reference.
(a) Request for reconsideration. A provider may request that the Department reconsider a decision to deny, reduce or recover payments because of third party liability. Such request shall be mailed to the Department by certified mail, return receipt requested within twenty days of the date the facility receives notice of the decision to deny, reduce or recover payments. The request shall 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 decision 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 part of the reconsideration process. Such a request shall be made in writing by certified mail, return receipt requested. The provider shall furnish 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) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.
(e) Informal resolution. The provider or the Department may request an informal meeting before the final decision on reconsideration to determine whether the matter may be resolved. The substance of the discussions and/or settlement offers made pursuant to an attempt at informal resolution shall not be admissible as part of a subsequent administrative hearing or judicial proceeding.
(f) Administrative hearing. A provider may request an administrative hearing regarding the final decision pursuant to Chapter I of these rules by mailing by certified mail, return receipt requested or personally delivering a request for hearing to the Department. Such request shall be mailed or delivered within twenty days of the date the provider receives notice of the final decision.
(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 I regarding a decision to deny, reduce or recover payments
Section 11. Superseding Effect. When promulgated, this Chapter supersedes all prior rules or policy statements issued by the Department, including Manuals or Bulletins, which are inconsistent with this Chapter.
Section 12. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in full force and 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 which implement, interpret or prescribe law or policy be promulgated as rules.
The Act provides that Medicaid is the payer of last resort. Accordingly, the Department must take all reasonable measures to ascertain the legal liability of third parties to pay for care and services for which Medicaid has made payments. In accordance with federal law, the Wyoming Act provides for the mandatory assignment of recipients' rights to the Department of payments for medical support. Federal regulations promulgated by the United States Department of Health and Human Services further specify the steps the Department is to take to determine the existence of third party liability and collect from third party payers for payments made from Medicaid funds.
Chapter 4 was promulgated to implement the third party liability and benefit recovery requirements of State and federal law. There have been important changes in those laws since Chapter 4 was promulgated, necessitating significant changes to the rule.
Chapter 4 is being divided into two. The third party liability provisions remain as part of the amended Chapter 4. The benefit recovery provisions of Chapter 4 have been greatly expanded (in response to State and federal law changes) and are now contained in proposed Chapter 35, which is being promulgated contemporaneously with this rule.
Chapters 4 and 35 are being promulgated as an emergency rules in order to timely implement recent changes in the Wyoming Act.