reglab/statecodes huggingface dataset:
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 3 - PROVIDER ENROLLMENT AND PARTICIPATION, PRE-AUTHORIZATION, PAYMENT AND SUBMISSION OF CLAIMS BY PROVIDERS › Section 3-6 - Provider Change in Ownership

Current through July 13, 2024
(a) A provider's Medicaid enrollment and any
				associated billing privileges are not transferrable and cannot be transferred
				at the time an individual provider's practice or a provider entity is sold or
				transferred.
(b) No party to a
				provider agreement shall assign or otherwise transfer any of its rights
				pursuant to that agreement.
(c) A
				provider shall not use its Medicaid enrollment or a provider agreement as
				collateral for any financial obligations.
(d) A provider which proposes a change in
				ownership, control, operation, management contract, or leasehold interest shall
				notify the Department in writing of the proposed change no later than sixty
				(60) days before the effective date of the proposed change.
(e) The prospective owner shall be required
				to enroll as a Medicaid provider in order to seek reimbursement for Medicaid
				covered services.
(f) A new owner
				shall not bill for claims until both the effective date of the sale or transfer
				has passed and the owner has been enrolled as a Medicaid provider.
(g) A provider entity that has changed
				ownership shall not be reimbursed for claims under the old provider agreement
				with dates of service on or after the effective date of the change in
				ownership.
(h) Wyoming Medicaid is
				not responsible for reimbursement of services provided during gaps in provider
				eligibility which arise as a result of a change in ownership.
(i) A change in the ownership of a provider
				entity as specified in this section shall not relieve the original provider of
				its obligations pursuant to the provider agreement or this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 3 - PROVIDER ENROLLMENT AND PARTICIPATION, PRE-AUTHORIZATION, PAYMENT AND SUBMISSION OF CLAIMS BY PROVIDERS › Section 3-7 - Out-of-State Providers

Current through July 13, 2024
(a) A service furnished by an enrolled
				provider located outside Wyoming is Medicaid reimbursable if:
(i) The services are needed because of a
				medical emergency;
(ii) The client
				is located outside of Wyoming and the client's health would be endangered if
				required to return to the state;
(iii) The Department determines, on the basis
				of medical advice, that the needed medical services, or necessary supplementary
				resources, are more readily available in the other state;
(iv) It is general practice for clients in a
				particular locality in Wyoming to use medical resources in another
				state;
(v) The client is referred
				to a provider outside Wyoming when prior authorized and comparable services are
				not available within the state;
(vi) The out-of-state provider is closer to
				the client's residence than a provider of comparable services within Wyoming;
				or
(vii) The client is less than 22
				years of age; and
(A) Is a foster child and in
				the custody of the Wyoming Department of Family Services who resides with a
				foster family out of state and whose Medicaid coverage cannot otherwise be
				transferred to the receiving state; or
(B) Has been placed in an out-of-state
				institution.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 3 - PROVIDER ENROLLMENT AND PARTICIPATION, PRE-AUTHORIZATION, PAYMENT AND SUBMISSION OF CLAIMS BY PROVIDERS › Section 3-8 - Provider Records

Current through July 13, 2024
(a) A provider shall collect and maintain
				medical and financial data, records, and information as necessary to provide
				services.
(b) A provider shall
				develop and maintain a record keeping system that includes a separate record
				for each client served.
(c) A
				provider shall maintain medical and financial records, including information
				regarding dates of service, diagnoses, services furnished, and claims, for at
				least six (6) years after the end of the state fiscal year in which payment for
				services was rendered.
(i) If any litigation,
				claim, audit or other action involving the records is initiated before the
				expiration of the six (6) year period, the records shall be maintained until
				the litigation, claim, audit or other action and any subsequent administrative
				or legal proceedings are resolved.
(ii) Such records shall be maintained for
				three (3) years in hard-copy, after which they may be maintained on
				micro-fiche, micro-film, or electronically.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 3 - PROVIDER ENROLLMENT AND PARTICIPATION, PRE-AUTHORIZATION, PAYMENT AND SUBMISSION OF CLAIMS BY PROVIDERS › Section 3-9 - Verification of Client Data

Current through July 13, 2024
(a) The Department issues Medicaid
				identification numbers to clients. The provider is responsible for verifying
				the validity of each client's Medicaid identification.
(b) The provider will not be paid for any
				claims submitted for treatment of an individual who does not have a valid
				Medicaid identification number. If a provider receives payment from an
				individual that is later determined to be eligible for Medicaid, the provider
				shall refund any such payment to the individual before seeking Medicaid
				reimbursement.
(c) If a provider
				furnishes services to an individual who purposely fails to notify the provider
				that he is a Medicaid client, the provider may submit a claim to Medicaid or
				seek reimbursement or payment from the client. A provider that elects to seek
				Medicaid reimbursement shall accept such payment as payment in full.
(d) A provider that furnishes services to an
				individual who becomes a Medicaid client after the date services were provided
				may submit a claim to the Department seeking Medicaid reimbursement for
				services furnished during the period the individual was eligible for
				Medicaid.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 3 - PROVIDER ENROLLMENT AND PARTICIPATION, PRE-AUTHORIZATION, PAYMENT AND SUBMISSION OF CLAIMS BY PROVIDERS › Section 3-10 - Prior Authorization

Current through July 13, 2024
(a) The Department may require prior
				authorization before provision of certain Medicaid covered services. The
				failure to obtain prior authorization before providing services precludes
				Medicaid reimbursement for such services. Prior authorization is not a
				guarantee of the client's eligibility or a guarantee of Medicaid
				payment.
(b) Before providing
				services that require prior authorization, the provider shall request such
				authorization using the forms specified by the Department.
(c) The Department shall grant a timely
				request for prior authorization if the proposed services are:
(i) Medically necessary;
(ii) Consistent with the diagnosis and
				treatment of the client's condition;
(iii) In accordance with the standards of
				good medical practice among the provider's peer group;
(iv) Required to meet the medical needs of
				the client and undertaken for reasons other than the convenience of the client
				and provider;
(v) Performed in the
				most cost effective and appropriate setting required by the client's condition;
				and,
(vi) Meet any additional
				criteria established by Wyoming Medicaid Rules or the coverage policies of the
				Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 3 - PROVIDER ENROLLMENT AND PARTICIPATION, PRE-AUTHORIZATION, PAYMENT AND SUBMISSION OF CLAIMS BY PROVIDERS › Section 3-11 - Medicaid Allowable Payment

Current through July 13, 2024
(a) The Department shall establish and
				maintain payment rates for Medicaid services to assure that payments are
				consistent with efficiency, economy, and quality of care and are sufficient to
				enlist enough providers so that care and services are available, to the extent
				that such care and services are available to the general population in the
				geographic area.
(b) Except as
				otherwise specified in this Chapter or the Wyoming Medicaid Rules, the Medicaid
				Allowable Payment shall not exceed the lower of the provider's usual and
				customary charges or the Medicaid fee schedule in effect on the date services
				were provided. The Medicaid fee schedule may include specific fees for services
				and/or a methodology for establishing such fees. The fee schedule is available
				upon request from the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 3 - PROVIDER ENROLLMENT AND PARTICIPATION, PRE-AUTHORIZATION, PAYMENT AND SUBMISSION OF CLAIMS BY PROVIDERS › Section 3-12 - Payment of Claims

Current through July 13, 2024
(a) Medicaid is the payer of last resort. A
				provider may not seek Medicaid payment for services furnished to a client until
				payment from third parties has been sought pursuant to Wyoming Medicaid Rules
				Chapter 35.
(b) For Medicaid
				enrolled providers, if the service is a covered service, a provider may not
				request, receive or attempt to collect any payment from the client or the
				client's family for the service, with the exception of section 9(c) of this
				Chapter. The provider shall accept the Medicaid allowable payment as payment in
				full for the services.
(c) A
				provider that provides a noncovered service to a client may seek payment from
				the client if the provider informed the client in writing of the client's
				potential liability before providing the service, and the client agreed in
				writing to pay for such services before they were furnished.
(d) A provider that provides a covered
				service to a client that is in excess of service limits may seek payment from
				the client if the provider informed the client in writing of the client's
				potential liability before providing the service, and the client agreed in
				writing to pay for such services before they were furnished.
(e) A provider may seek copayment from
				clients as permitted by Department policy as reflected in the Department's
				manuals and bulletins. The amount of the permitted copayment shall be
				automatically deducted by the Department from the Medicaid Allowable Payment.
				Collection of a permitted copayment is at the discretion of the
				provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 3 - PROVIDER ENROLLMENT AND PARTICIPATION, PRE-AUTHORIZATION, PAYMENT AND SUBMISSION OF CLAIMS BY PROVIDERS › Section 3-14 - Reconsideration

Current through July 13, 2024
The Department shall recover overpayments pursuant to the
				  Wyoming Medicaid Rules Chapter 16.
In addition to using its own internal processes for recovery
				  of overpayments, the Department may refer a matter involving suspected
				  overpayments to the MFCU at any time.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Department of Health
				  pursuant to the Medical Assistance and Services Act at Wyoming Statute §
									
										42-4-101,
et seq
.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter shall apply to all contested
				cases involving Medicaid in accordance with Medicaid rules, except as otherwise
				specified in the Department's Medicaid rules.
(b) The Department may issue manuals and
				bulletins to interpret this Chapter. The provisions contained in manuals or
				bulletins shall be subordinate to this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-3 - Definitions

Current through July 13, 2024
Except as otherwise specified in Chapter 1 of the Wyoming
				  Department of Health's Medicaid Rules, the terminology used in this Chapter is
				  the standard terminology and has the standard meaning used in health care,
				  Medicaid, and Medicare.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-4 - Right to Hearing

Current through July 13, 2024
(a) An applicant has a right to a hearing if
				their application is denied or not acted upon within the time frames specified
				by the Department.
(b) A client has
				a right to a hearing if eligibility or services are denied, reduced, terminated
				or suspended.
(c) A provider has a
				right to a hearing regarding an adverse action following the request for
				reconsideration as specified in Chapter 16 of the Wyoming Department of
				Health's Medicaid Rules.
(d)
				Pharmaceutical manufacturers shall have the same rights to a hearing as
				providers.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-5 - Notice of Right to Hearing and Adverse Action

Current through July 13, 2024
(a) Applicants and clients. The Department
				shall provide notice at the time of any adverse action. The notice shall
				include:
(i) An explanation of:
(A) The individual's right to request a
				hearing; or
(B) An explanation of
				circumstances where a hearing will be granted based on a change in the
				law.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-6 - Time of Notice

Current through July 13, 2024
(a) Applicants. The Department shall mail the
				notice after a final determination is made.
(b) Clients. The Department shall mail notice
				of adverse action at least ten (10) business days before the effective date,
				except:
(i) The Department may mail notice,
				not less than five (5) business days before the effective date if, the
				circumstance indicate probable fraud by a client, and if possible, there are
				facts that have been verified through secondary sources.
(ii) The Department may mail notice not later
				than the effective date if:
(A) The
				Department has been notified that a client is deceased;
(B) The Department receives a clear written
				statement signed by a client that:
(I) The
				client no longer wishes to receive services; or
(II) Provides information which requires
				termination or reduction of services. The statement must also include that the
				client understands that by providing the Department with the information,
				immediate termination or reduction of the client's services will
				result;
(C) The client
				has been admitted to an institution where the client is ineligible under the
				plan for further services.
(D) The
				client's whereabouts are unknown and the Department's mail is returned,
				indicating there is no forwarding address;
(E) The Department establishes that the
				client has been accepted for benefits by another local jurisdiction, state,
				territory or commonwealth;
(F) A
				change in the level of medical care is prescribed by the client's physician;
				or
(G) The notice involves an
				adverse determination based on preadmission screening requirements for
				individuals with mental illness or intellectual disability.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-7 - Request for Hearing

Current through July 13, 2024
(a) A client's request for a hearing shall be
				submitted electronically via email to the Department, made verbally to the
				Department, mailed to the Department via certified mail, return receipt
				requested, or personally delivered to the Department within twenty (20)
				business days after the mailing of the notice of adverse action.
(b) A provider's request for a hearing shall
				be mailed via certified mail, return receipt requested, or personally delivered
				to the Department within twenty (20) business days after the mailing of the
				notice of adverse action.
(i) A provider's
				request for hearing shall state with specificity the reasons for the request.
				Failure to provide a statement of reasons shall result in the dismissal of the
				request with prejudice.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-8 - Procedure after Request for Hearing

Current through July 13, 2024
(a) The Department shall evaluate the request
				and, within ten (10) business days following the receipt of the request notify
				the requesting party in writing whether the request has been accepted or
				rejected.
(b) Denial of hearing.
(i) The Department may deny a request for
				hearing if the action complained of is not an adverse action as defined, or the
				request does not meet the requirements of this Chapter.
(ii) A denial of a request for hearing is a
				final decision of the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-9 - Maintaining Services Pending Appeal

Current through July 13, 2024
(a) If the Department mails the required
				notice and the client requests a hearing before the effective date of the
				action, the Department may not terminate or reduce services until the final
				decision is rendered after the hearing unless:
(i) The Hearing Officer determines at the
				hearing that the sole issue is one of federal or state law or policy;
				and
(ii) The Department promptly
				informs the client in writing that services are to be terminated or reduced
				pending the final decision.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-10 - Hearing Procedures

Current through July 13, 2024
In addition to the specific Sections to follow, all contested
				  case hearings shall be conducted in accordance with the Office of
				  Administrative Hearings Rules, specifically Chapter 2 of the Uniform Rules for
				  Contested Case Practice and Procedure.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-11 - Timing of Hearing

Current through July 13, 2024
A hearing shall be held within forty (40) days of the request
				  for hearing unless otherwise provided by law, by agreement of the parties, or
				  if a contestant requests a continuance.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-12 - Representation

Current through July 13, 2024
(a) Any applicant, client, or provider has
				the right to represent themselves, to be represented by a lawyer admitted to
				practice in Wyoming, or, by an authorized representative, if the contestant is
				an applicant or client.
(i) The contestant
				shall notify the Department in writing if the contestant intends to be
				represented for the hearing.
(ii) A
				non-lawyer authorized to represent an applicant or client may advocate for the
				applicant or client in a representative capacity, draft pleadings or other
				documents. However, this section does not authorize a person, who is not a
				lawyer admitted to practice in Wyoming, to provide legal advice or services, or
				represent any person before the courts of the State of
				Wyoming.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-13 - Decisions

Current through July 13, 2024
(a) The hearing officer shall make proposed
				findings of fact and conclusions of law within twenty (20) business days of the
				close of the hearing and forward them to the Director for the final decision.
				This time may be extended if the parties or other interested persons are to
				submit briefs; but may not be extended by more than ten (10) working days,
				unless the parties stipulate, in writing or on the record at the hearing, to a
				later date.
(i) Within ten (10) business days
				of the close of the hearing, or such additional time as the hearing officer may
				allow, each party shall be allowed to file with the hearing officer any
				proposed findings of fact and conclusions of law, together with a supporting
				brief. Such proposals and briefs shall be served on all other
				parties.
(ii) Within ten (10)
				business days after the issuance of the hearing officers proposed findings of
				fact and conclusions of law, any of the parties may submit exceptions. Such
				exceptions shall be filed with the Director and served on all other
				parties.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-14 - Appeals

Current through July 13, 2024
Appeals from a final decision of the Department shall be in
				  accordance with W.S. §
									
										16-3-114 through
				  16-3-115,
				  and Rule 12 of the Wyoming Rules of Appellate Procedure.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-15 - Transcripts and Record

Current through July 13, 2024
(a) When a contested case is set for hearing,
				the Department shall assign a docket number to the case and enter the case with
				its number and date of filing on a docket. The Department shall maintain a
				separate file for each docketed case in which all pleadings, transcriptions,
				correspondence, papers, and exhibits for that case shall be maintained. All
				items shall have noted thereon the assigned docket number and the date of
				filing.
(b) All contested case
				hearing proceedings shall be recorded, electronically, through the use of a
				qualified court reporter, or any other appropriate means determined by the
				agency or the hearing officer. Transcriptions of oral proceedings or written
				transcripts of a witness's testimony may be obtained by contestant from the
				Department upon payment of the cost.
(i) In a
				nonpublic investigatory proceeding, requests for copies or transcripts may be
				limited to testimony of the requesting party.
(ii) Where a contestant can demonstrate
				indigence and cannot effectively perfect his or her appeal without a
				transcript, the Department may waive the payment of the fee.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 4 - MEDICAID ADMINISTRATIVE HEARINGS › Section 4-16 - Incorporation by Reference

Current through July 13, 2024
(a) For any code, standard, rule, or
				regulation incorporated by reference in these rules:
(i) The Department of Health has determined
				that incorporation of the full text in these rules would be cumbersome or
				inefficient given the length or nature of the rules.
(ii) The incorporation by reference does not
				include any later amendments or editions of the incorporated matter beyond the
				applicable date identified in this section; and
(iii) The incorporated code, standard, rule,
				or regulation is maintained at the Department of Health and is available for
				public inspection and copying at cost at the same location.
(iv) The Department incorporates the
				administrative practice and procedure rules found in Chapter 2 of the Uniform
				Rules for Contested Case Practice and Procedure adopted by the Office of
				Administrative Hearings and effective July 20, 2017 found at:
http//soswy.state.wy.us/Rules/RULES/9644.pdf
https://rules.wyo.gov
, Reference
				Number 270.0001.2.07202017.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-1 - Authority

Current through July 13, 2024
This rule is promulgated by the Department of Health pursuant
				  to W. S. §
									
										42-4-101
et seq.
,
				  and the Wyoming Administrative Procedures Act at W. S. §
									
										16-3-101
et
				  seq.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter
				establishes the standards and procedures for imposing remedies on nursing
				facilities which participate in the Medicaid program and which are not in
				compliance with the requirements of participation of the Medicaid program. It
				is intended to ensure prompt compliance with the requirements of
				participation.
(b) This Chapter is
				to be read in conjunction with:
(i)
				Applicable federal statutes and regulations, including 42 C.F.R. Parts 401,
				431, 435, 441, 441, 447, 483, 488, 489 and 498, as amended effective July 1,
				1995. If there are inconsistencies between the provisions of this Chapter and
				federal statutes and/or regulations, including additional or different
				substantive or procedural requirements, the federal statutes and/or regulations
				shall control the provisions of this Chapter; and
(ii) The State Operations Manual (SOM).
				Except as otherwise specified in this Chapter, the procedures and standards of
				the SOM shall control procedures for the imposition of remedies.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-3 - General provisions

Current through July 13, 2024
(a) The Department
				may issue Manuals or Bulletins to providers and/or other affected parties to
				interpret the provisions of this Chapter. Such Manuals and Bulletins shall be
				consistent with and reflect the policies contained in this Chapter. The
				provisions contained in Manuals or Bulletins shall be subordinate to the
				provisions of this Chapter.
(b) The
				Department may refer suspected abuse or neglect to the appropriate local, state
				and/ or federal agencies for investigation.
(c) Available remedies. The Department is
				authorized to impose one or more of the following remedies for each deficiency:
(i) Directed in-service training;
(ii) Directed plan of correction;
(iii) Appointment of a State
				monitor;
(iv) Denial of Medicaid
				payments for new admissions;
(v)
				Denial of fifty percent of the State share of Medicaid payments;
(vi) Denial of the Federal share of Medicaid
				payments;
(vii) Reimbursement of
				resident losses;
(viii) Appointment
				of a temporary manager;
(ix)
				Termination of Medicaid provider agreement with transfer of residents and
				assessment of transfer costs; or
(x) Closure of facility with transfer of
				residents and assessment of transfer costs.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-4 - Definitions

Current through July 13, 2024
(a) "Abbreviated standard survey".
				"Abbreviated standard survey" as defined by
				42
				C.F.R. §
										488.301, which definition is
				incorporated by this reference.
(b)
				"Abuse". "Abuse" as defined by
				42
				C.F.R. §
										488.301, which definition is
				incorporated by this reference.
(c)
				"Alternative remedies". The following remedies selected by the Department as
				alternatives to federally mandated remedies pursuant to
				42 C.F.R. §
										488.406(a)(8):
(i) Assessment of transfer costs;
(ii) Denial of the Federal share of Medicaid
				payments;
(iii) Denial of the fifty
				percent of the State share of Medicaid payments; and
(iv) Reimbursement of resident
				losses.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-5 - Factors to be considered in selecting remedies

Current through July 13, 2024
The Director shall consider the factors specified in
				  42 C.F.R. §
										488.404, which is incorporated by this
				  reference, in determining the seriousness of a facilitys deficiency(ies) and
				  selecting the appropriate remedy(ies).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-6 - Available remedies

Current through July 13, 2024
Remedies are grouped into the following categories pursuant
				  to
				  42 C.F.R. §
										488.408:
(a) Category 1 remedies.
(i) Directed in-service training;
(ii) Directed plan of correction;
				and/or
(iii) The appointment of a
				state monitor.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-7 - Selection of remedies

Current through July 13, 2024
(a) The Department
				shall follow the procedures and methods specified in
				42 C.F.R. §
										488.408, as supplemented by the SOM, both of
				which is incorporated by this reference, in selecting remedies.
(b) For purposes of selecting remedies, the
				alternative remedies shall be classified as specified in Section
				6,
				and may be imposed whenever remedies of the specified category are appropriate
				pursuant to 42 C.F.R. Subpart F, as supplemented by the SOM.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-8 - Action when there is immediate jeopardy

Current through July 13, 2024
(a) When there is
				immediate jeopardy, the Department shall take action pursuant to
				42 C.F.R. §
										488.410, as supplemented by the SOM, both of
				which are incorporated by this reference.
(b) The Department shall follow the
				procedures specified in
				42 C.F.R. §
										488.410, as supplemented by the
				SOM.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-9 - Imposition of remedies when there is no immediate jeopardy but the facility is not in substantial compliance

Current through July 13, 2024
(a) When there is
				no immediate jeopardy, but a facility is not in substantial compliance, the
				Department shall take action pursuant to
				42 C.F.R. §
										488.412, as supplemented by the SOM, both of
				which are incorporated by this reference.
(b) The Department shall follow the
				procedures specified in
				42 C.F.R. §
										488.412, as supplemented by the
				SOM.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-10 - Imposition of remedies when there is repeated substandard quality of care

Current through July 13, 2024
(a) When a facility has been found to have
				provided substandard quality of care on the last three consecutive standard
				surveys, the Department shall take action pursuant to
				42 C.F.R.
				§
										488.414, as supplemented by the SOM,
				both of which are incorporated by this reference.
(b) The Department shall follow the
				procedures specified in
				42 C.F.R.
				§
										488.414, as supplemented by the
				SOM.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-11 - Temporary management

Current through July 13, 2024
The Department adopts the provisions of
				  42 C.F.R. §
										488.415, as supplemented by the SOM, both of
				  which are incorporated by this reference, relating to the appointment of a
				  temporary manager.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-12 - Denial of payments for new admissions

Current through July 13, 2024
The Department adopts the provisions of
				  42 C.F.R. §
										488.417, as supplemented by the SOM, both of
				  which are incorporated by this reference, relating to the denial of payments
				  for new admissions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-13 - State monitoring

Current through July 13, 2024
The Department adopts the provisions of
				  42 C.F.R. §
										488.422, as supplemented by the SOM, both of
				  which are incorporated by this reference, relating to state
				  monitoring.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-14 - Directed plan of correction

Current through July 13, 2024
The Department adopts the provisions of
				  42 C.F.R. §
										488.424, as supplemented by the SOM, both of
				  which are incorporated by this reference, relating to directed plans of
				  correction.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-15 - Directed in service training

Current through July 13, 2024
The Department adopts the provisions of
				  42 C.F.R. §
										488.425, as supplemented by the SOM, both of
				  which are incorporated by this reference, relating to directed in service
				  training.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-16 - Closure of a facility or transfer of residents, or both

Current through July 13, 2024
The Department adopts the provisions of
				  42
				  C.F.R. §
										488.426, as supplemented by the
				  SOM, both of which are incorporated by this reference, relating to the closure
				  of a facility or transfer of residents, or both.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-17 - Alternative remedies

Current through July 13, 2024
(a) The Department
				has adopted alternative remedies pursuant to
				42 C.F.R. §
										488.406(a)(8)
(b) Alternative remedies are classified
				pursuant to Section
				6 as
				category 2 or category 3 remedies.
(i)
				Alternative remedies classified as category 2 remedies may be imposed whenever
				the imposition of category 2 remedies is appropriate according to 42 C.F.R.
				Subpart F. In imposing category 2 alternative remedies, the Department shall
				follow the procedures of Sections 7510 through 7536 of the SOM.
(ii) Alternative remedies classified as
				category 3 remedies may be imposed whenever the imposition of category 3
				remedies is appropriate according to 42 C.F.R. Subpart F. In imposing category
				3 alternative remedies, the Department shall follow the procedures of Sections
				7510 through 7536 of the SOM.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-18 - Duration of remedies

Current through July 13, 2024
(a) The Department
				adopts the provision of
				42 C.F.R. §
										488.454, which are incorporated by this
				reference, relating to the duration of remedies.
(b) Alternative remedies. Alternative
				remedies shall remain in effect until the facility is in substantial compliance
				as determined by the survey agency, or until the provider agreement is
				terminated.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-19 - Termination of provider agreement

Current through July 13, 2024
The Department adopts the provisions of
				  42 C.F.R. §
										488.456, which are incorporated by this
				  reference, relating to the termination of provider agreement.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-20 - Informal dispute resolution

Current through July 13, 2024
(a) Availability.
				Informal dispute resolution is available whenever the survey agency notifies a
				facility of noncompliance.
(b)
				Request. A request for informal dispute resolution shall be made in writing and
				hand-delivered or mailed by certified mail, return receipt requested, and
				delivered to the survey agency within ten calendar days after the facility
				receives a statement of deficiencies.
(c) Conduct of meeting. Informal dispute
				resolution shall consist of a face-to-face meeting between representatives of
				the facility and representative of the survey agency.
(d) Scope of informal dispute resolution.
(i) The purpose of informal dispute
				resolution is to allow a provider an opportunity to demonstrate that
				deficiencies should not have been cited.
(ii) A facility may not use the informal
				dispute resolution process to challenge any part of the survey process,
				including the:
(A) Classification of
				deficiencies;
(B) Directors choice
				of remedy(ies) imposed;
(C) Failure
				of the survey agency to comply with a requirement of the survey
				process;
(D) Inconsistency of the
				survey team in citing deficiencies among facilities; or
(E) Inadequacy or inaccuracy of the informal
				dispute resolution process.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-21 - Readmission

Current through July 13, 2024
(a) After termination of Medicaid provider
				agreement or closure and transfer of residents or voluntary withdrawal, a
				facility may not participate in Medicaid unless:
(i) The reasons for the termination of
				Medicaid provider agreement, closure and transfer of residents, or voluntary
				withdrawal no longer exist;
(ii)
				There is reasonable assurance that the reasons for the termination of Medicaid
				provider agreement, closure and transfer of residents, or voluntary withdrawal
				will not recur; and
(iii) The
				facility has received a certification of compliance.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-22 - Effect of imposition of Medicare sanctions on dually certified facilities

Current through July 13, 2024
(a) Automatic imposition. If a facility is
				denied participation in, terminated from participation in Medicare, or
				otherwise sanctioned by Medicare, the Department shall impose the same remedy
				or remedies for purposes of Medicaid, in accordance with the provisions of
				42
				C.F.R. §
										488.452.
(b) No separate appeal. A remedy imposed
				pursuant to this Section may not be appealed pursuant to Section
				23
				of this rule, Chapter I, or any other rules of the Department. The providers
				exclusive appeal is pursuant to Medicare procedures in accordance with
				42 C.F.R. §
										498.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-23 - Appeal rights

Current through July 13, 2024
(a) Request for
				administrative hearing. A facility may request an administrative hearing at
				which it may refute the certification of noncompliance upon which the
				imposition of remedies is based, in accordance with the provisions of
				42 C.F.R. §
										431, Subpart D. The administrative hearing
				shall be pursuant to Chapter I and shall be requested by mailing by certified
				mail, return receipt requested, or personally delivering a written request for
				hearing to the Department within sixty days of the date the facility receives
				notice of the imposition of remedies. The request for hearing shall state with
				specificity the factual basis for the request. The failure to provide such
				specificity shall result in the denial of the request, with
				prejudice.
(b) Time of hearing. The
				administrative hearing shall be held before the effective date of the remedy or
				within 120 calendar days
after
the effective date of
				the remedy.
(c) No stay of remedy.
				The filing of a request for an administrative hearing shall not stay the
				effective date of the remedy.
(d)
				Matters not subject to appeal. A facility may not request an administrative
				hearing regarding:
(i) The scope and severity
				of noncompliance; or
(ii) The
				Director's choice of remedy.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-24 - Superseding effect

Current through July 13, 2024
This Chapter supersedes all prior rules or policy statements
				  issued by the Department, including Provider Manuals and/or Provider Bulletins,
				  which are inconsistent with this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 5 - MEDICAID LONG TERM CARE FACILITY REMEDIES/TERMINATIONS › Section 5-25 - Severability

Current through July 13, 2024
If any portion of this Chapter is found to be invalid or
				  unenforceable, the remainder shall continue in full force and
				  effect.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-1 - Authority

Current through July 13, 2024
This rule is promulgated by the Department of Health pursuant
				  to W.S. §
									
										42-4-101
et seq
. and
				  the Wyoming Administrative Procedures Act at W. S. §
									
										16-3-101
et
				  seq
.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-2 - Applicability

Current through July 13, 2024
(a) This rule shall apply to and govern the
				provision of and reimbursement of HEALTH CHECK program services, formerly known
				as EPSDT services, provided to recipients under age twenty-one. It shall apply
				to all recipients and HEALTH CHECK providers.
(b) The Department may issue Manuals or
				Bulletins to HEALTH CHECK providers and/or other affected parties to interpret
				the provisions of this rule. Such Manuals or 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 this
				Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-3 - General Provisions

Current through July 13, 2024
(a) Terminology.
				Except as otherwise specified, the terminology used in this rule is the
				standard terminology and has the standard meaning used in accounting, health
				care, Medicaid and Medicare.
(b)
				This Chapter is intended to be read consistently with applicable federal
				statutes, including OBRA' 89, and HHS regulations.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-5 - Provider participation

Current through July 13, 2024
(a) Compliance with
				Chapter 3. An individual or entity which wishes to receive Medicaid funds for
				HEALTH CHECK program services furnished to a recipient must meet the
				requirements of Chapter 3, which requirements are incorporated by this
				reference.
(b) Eligible HEALTH
				CHECK providers. Physicians, nurse practitioners, nurse midwives and public
				health nurses that are:
(i) In public
				practice, including employees of federally qualified-health centers (FQHCs),
				rural health clinics (RTCs) and Indian Health Services Clinics, or private
				practice; and
(ii) Deliver primary
				care services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-6 - Provider Records

Current through July 13, 2024
(a) Compliance with
				Chapter 3. A HEALTH CHECK provider must comply with the record keeping
				requirements of Chapter 3, which are incorporated by this reference.
(b) HEALTH CHECK requirements. The medical
				record for each recipient that receives HEALTH CHECK services must include
				documentation that all required components of such services have been
				furnished.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 6 - HEALTH CHECK (FORMERLY EPSDT) PROGRAM › Section 6-8 - Covered services

Current through July 13, 2024
(a) HEALTH
				CHECKs.
(b) Treatment and referral
				services. Treatment and referral services are covered pursuant to the other
				rules of the Department.
(c)
				Expanded services. Expanded services are covered services if:
(i) There is a physician referral;
(ii) Prior authorized, if required;
				and
(iii) Furnished in the most
				cost effective setting, as determined by the Division.