reglab/statecodes huggingface dataset:
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-3 - Definitions

Current through July 13, 2024
Except as otherwise specified in Chapter 1, the terminology
				  used in this Chapter is the standard terminology and has the standard meaning
				  used in healthcare, Medicaid, and Medicare.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-4 - General Provisions

Current through July 13, 2024
(a) General
				methodology. The Department shall review designated admissions and proposed
				admissions for inpatient hospital services to ensure the appropriateness and
				medical necessity of such services.
(b) The failure to comply with this Chapter
				shall result in the denial of certification and, if appropriate, recovery of
				Medicaid payments. A provider may not bill a client if there has been a denial
				of certification or recovery of Medicaid payments.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-5 - Non-emergent Admissions

Current through July 13, 2024
(a) Designated
				non-emergent admissions shall receive admission certification before the
				clients admission.
(b) The
				Department may, from time to time, designate those non-emergent admissions
				which require the admission certification procedures set forth in Section
				6.
(i) The Departments designation of admission
				certification procedures shall be based on:
(A) Clinical consultation with health care
				professionals;
(B) Applicable
				Centers for Medicare & Medicaid Services guidelines; and
(C) The potential for
				over-utilization.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-6 - Procedure for Admission Certification

Current through July 13, 2024
(a) The hospital or
				its designee shall notify the Department at least three (3) working days prior
				to the proposed admission and provide the information required by Sections
				9(b) and
				(c) of this Chapter.
(b) Notice from the hospital or its designee
				shall be given in writing as required by the Department.
(c) Upon receipt of the information required
				by Sections
				9(b) and
				(c) of this Chapter, a clinical evaluator
				shall review the information and determine whether the admission meets the
				medical necessity criteria.
(i) If the
				clinical evaluator determines the admission meets the medical necessity
				criteria, the Department shall issue a Prior Authorization (PA) number, which
				shall be communicated by an admission certification letter to the attending
				physician or the hospital as required by the Department, by the end of the next
				working day after the determination.
(ii) An inpatient hospital service which is
				not a covered service shall not receive a PA number.
(iii) If the clinical evaluator is unable to
				determine that the admission meets the medical necessity criteria, the
				evaluator shall refer the matter to a physician adviser.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-7 - Continued Stay Review for Emergency Admissions

Current through July 13, 2024
(a) Notice to
				Department. A hospital shall request a continued stay review of an emergency
				admission which results in the provision of inpatient hospital services which
				require an admission certification.
(b) Review by Department. The Department
				shall conduct a continued stay review of any emergency admission which results
				in the provision of inpatient hospital services to a client.
(c) Medicaid payments. There shall be no
				Medicaid payments to any provider of inpatient hospital services except to the
				extent that the continued stay review results in an admission certification.
				Medicaid payments for inpatient hospital services shall be pursuant to State
				Plan Amendment, Attachment 4.19a, Part 1.
(d) Procedures for continued stay review. The
				hospital shall:
(i) Notify the Department of
				the admission and provide the information required in Sections
				9(b) and
				(c) of this Chapter by the end of the next
				working day after the admission. Notification shall be in writing as required
				by the Department.
(ii) Failure to
				timely request a continued stay review shall result in the denial of Medicaid
				payment for inpatient services furnished to the client before the date of the
				request.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-8 - Medical Necessity Criteria

Current through July 13, 2024
(a) The Department
				shall, in consultation with appropriate medical and other health care
				professionals, develop criteria to determine the medical necessity and
				appropriateness of inpatient hospital services. The criteria shall reflect
				prevailing norms of medical practice.
(b) Admission certification shall be denied
				unless the request meets the medical necessity criteria.
(c) The medical necessity criteria may be
				obtained from the Department by written request.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-9 - Hospital Responsibilities

Current through July 13, 2024
A hospital which seeks Medicaid payment for inpatient
				  hospital service provided to a client shall:
(a) Obtain an admission certification
				pursuant to this Chapter, if required.
(b) Request a written admission form to
				provide certification by contacting the Department in writing as required by
				the Department and provide the following information:
(i) The attending physicians name and
				National Provider Identifier (NPI) number;
(ii) The clients name, Medicaid
				identification number and date of birth;
(iii) The name of the hospital;
(iv) The principal diagnosis by narrative
				description or diagnostic code according to the International Classification of
				Disease (ICD), as specified by the Department;
(v) The primary procedure by narrative
				description or procedure code according to the Current Procedural Terminology
				(CPT), as specified by the Department;
(vi) Whether the admission is a
				readmission;
(vii) The expected
				date of admission; and
(viii)
				Information from the plan of care and information concerning the reason for
				admission as requested by the Department to determine if admission meets the
				medical necessity criteria.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-10 - Department Responsibilities

Current through July 13, 2024
The Department shall:
(a) Obtain and review the information
				required by Sections
				9(b) and
				(c) of this Chapter;
(b) Determine whether the admission met or
				meets the medical necessity criteria.
(c) Inform the attending physician and the
				hospital of the determination, in writing as required by the Department, by the
				end of the next working day after the determination;
(d) Mail a written notice of the admission
				certification determination to the attending physician and the
				hospital;
(e) Determine that all
				diagnosis and procedure coding satisfies ICD and CPT;
(f) Determine if the admission of a
				retroactively eligible client met the medical necessity criteria;
(g) Provide for an appeal of denial of
				certification;
(h) Recruit and
				coordinate the work of the physician advisers;
(i) Notify the attending physician and the
				person responsible for the hospitals utilization review in writing or as
				required by the Department, of an appeal decision by the end of the next
				working day after the decision; and
(j) Mail a written notice of the appeal
				decision to the attending physician and the hospital.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-11 - Retroactive Eligibility

Current through July 13, 2024
(a) A hospital may
				seek admission certification for a client found retroactively eligible for
				Medicaid benefits after the date of admission for services which require
				admission certification. An attending physician and a hospital shall not seek
				admission certification for a person whose application for Medicaid is pending
				at the time of admission.
(b)
				Procedure. The hospital shall request admission certification within thirty
				(30) calendar days after the hospital receives notice of eligibility. The
				request for certification shall be in writing and shall include the information
				required by Sections
				9(b) and
				(c) of this Chapter. The request shall also
				include:
(i) A statement of the date and
				method of notice of eligibility; and
(ii) A copy of the clients complete medical
				record, submitted at the hospitals expense, which can be mailed or scanned to
				the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-12 - Medicare Admissions

Current through July 13, 2024
(a) An admission
				which has been approved under Medicare is exempt from this Chapter.
(b) The denial of reimbursement for an
				inpatient hospital service under Medicare because the service is not medically
				necessary shall also preclude Medicaid payment for the service, and the
				provider(s) of such services may not request an appeal or an administrative
				hearing pursuant to this rule or other rules of the Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-13 - Post-payment Reviews

Current through July 13, 2024
(a) The Department
				may conduct a post-payment review to determine whether:
(i) All procedural requirements of this
				Chapter were met;
(ii) The
				admission met the medical necessity criteria;
(iii) All appropriate services were
				provided;
(iv) All services
				provided were medically necessary and appropriate;
(v) All services were provided in conformance
				with prevailing norms of medical practice;
(vi) Diagnosis and procedure coding meets ICD
				and CPT; and
(vii) Revenue coding
				is appropriate.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-14 - Information Used For Determination

Current through July 13, 2024
At any stage of the admission certification process,
				  including an appeal, the reviewer may make a decision based on the information
				  provided by the attending physician or hospital, or, in the reviewers sole
				  discretion, the reviewer may request and refer to additional facts submitted by
				  the attending physician or hospital. Such information shall be submitted at the
				  expense of the provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-15 - Ineligibility to Serve as Physician Adviser

Current through July 13, 2024
A physician shall not be eligible to serve as a physician
				  adviser if:
(a) The physician is the
				attending physician;
(b) During the
				previous twelve (12) months, the physician issued treatment orders or
				participated in the formulation or execution of the treatment plan for the
				client for whom admission certification is requested;
(c) The physician or the physicians spouse,
				child, grandchild, parent, or grandparent, has an ownership interest of five
				percent (5%) or more in the hospital for which admission certification is being
				requested; or
(d) The physician can
				obtain a financial benefit from the admission of the client.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-16 - Interpretation of Chapter

Current through July 13, 2024
(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.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION › Section 8-19 - Severability

Current through July 13, 2024
If any portion of these rules is found to be invalid or
				  unenforceable, the remainder shall continue in full force and effect. October
				  23, 1998 (Final)
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Department of Health
				  pursuant to the Medical Assistance and Services Act at W.S. §
									
										42-4-101
et seq.
and
				  the Wyoming Administrative Procedure Act at W.S. §
									
										16-3-101
et
				  seq.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter
				shall apply to and govern the participation in the Medicaid program by
				providers of inpatient or outpatient hospital services. It is intended to be
				read in conjunction with the other rules of the Department, including but not
				limited to, Chapters 8, 24, 26, 30, 31, 32 and 33. This Chapter shall apply to
				services furnished on or after its effective date.
(b) The Department may issue Provider
				Manuals, Provider Bulletins, or both, 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.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-5 - Provider participation

Current through July 13, 2024
(a) Payments only
				to providers. Except as otherwise specified in this Chapter, no hospital that
				furnishes covered services to a recipient shall receive Medicaid funds unless
				the provider is certified, has signed a provider agreement, and is
				enrolled.
(b) Compliance with
				Chapter 3. A hospital that wishes to receive Medicaid reimbursement for covered
				services furnished to a recipient must meet the provider participation
				requirements of Chapter 3, which requirements are incorporated by this
				reference.
(c) Additional
				provisions. In addition to the requirements of Chapter 3, the following
				provisions apply to hospitals that are providers.
(i) A provider which is terminated as a
				Medicaid provider because of the loss of licensure shall not be entitled to
				reconsideration or an administrative hearing except as provided by the rules of
				the survey agency.
(ii) A provider
				which is terminated as a Medicaid provider because of the loss of Medicare
				certification shall not be entitled to reconsideration or an administrative
				hearing pursuant to this Chapter or any other rules of the
				Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-9 - Inpatient hospital services

Current through July 13, 2024
(a) Covered
				services. Subject to the service limitations of Section
				11,
				inpatient hospital services are covered services if provided:
(i) Pursuant to the written orders of a
				physician;
(ii) By or under the
				supervision of a physician; and
(iii) Subject to subsections (b) and
				(c)
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-10 - Outpatient hospital services

Current through July 13, 2024
(a) Covered
				services. Subject to the service limitations of Section
				11,
				outpatient hospital services are covered services if provided:
(i) Pursuant to the written orders of a
				physician;
(ii) By or under the
				supervision of a physician and
(iii) Subject to subsection (b).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-11 - Service limitations

Current through July 13, 2024
(a) Outpatient
				hospital services.
(i) Generally. Medicaid
				reimbursement for outpatient hospital services shall be limited to a total of
				twelve visits per calendar year to a hospital clinic, a hospital emergency room
				(for non-emergency services), and/or a physician's office, unless additional
				visits are prior authorized.
(ii)
				Physical therapy services. Medicaid reimbursement for physical therapy services
				shall be limited to a total of twenty visits per calendar year to a hospital,
				independent physical therapist or a physicians office, unless additional visits
				are prior authorized.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-12 - Ancillary services

Current through July 13, 2024
(a) Durable medical
				equipment provided by a hospital to a recipient for home use is covered
				pursuant to the rules and policies of the Department if the hospital is
				enrolled as a Medicaid provider of medical supplies.
(b) Laboratory services are covered if based
				on specific, written orders of a physician;
(i) Specimen collection fees are reimbursable
				only to the provider that extracts the specimen;
(ii) Only one collection fee is allowed for
				each type of specimen for each recipient encounter, regardless of the number of
				specimens extracted;
(iii) Clinical
				laboratory services routinely performed by non-physicians are not entitled to a
				professional component;
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-13 - Out-of-state hospitals

Current through July 13, 2024
(a) Hospital
				services provided within the service area but outside the State of Wyoming are
				not covered unless:
(i) The hospital service
				is not available within the recipients local trade area, the out-of-state
				hospital is closer to the recipient's residence than an in-state hospital which
				offers the necessary services, and the hospital has executed a provider
				agreement before the admission;
(ii) The hospital service is provided in
				response to an emergency; or
(iii)
				The recipient was, at the time the hospital services were provided, outside the
				service area and the recipient's health would have been endangered if the
				recipient had been required to travel to a hospital within the service
				area.
(iv) The recipient is less
				than 19 years of age, and
(A) Is a foster
				child not covered by Title IV-E of the Social Security Act and resides with a
				foster family out of state; or
(B)
				Has been placed in an out-of-state institution.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-14 - Copayment

Current through July 13, 2024
(a) Outpatient hospital services. Except as
				provided in subsection (b), a recipient must pay a $6.00 copayment for each
				outpatient hospital visit.
(b)
				Exceptions. The following recipients are exempt from the copayment provision of
				subsection (a):
(i) An individual seeking
				emergency services;
(ii) An
				individual seeking family planning services;
(iii) An individual under age 21;
(iv) A pregnant woman or a woman that seeks
				hospital services within six weeks after the delivery of her child;
(v) A resident of a nursing facility;
				and
(vi) A recipient that is also
				eligible for Medicare.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-15 - Medicaid allowable payment for hospital services

Current through July 13, 2024
(a)
				Inpatient hospital services. Except as specified otherwise pursuant to Chapter
				31, in patient hospital services are reimbursed pursuant to Chapters 30 and
				32.
(b) Outpatient hospital
				services. Except as specified otherwise pursuant to Chapter 31, outpatient
				hospital services are reimbursed pursuant to Chapter 33.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 9 - HOSPITAL SERVICES › Section 9-19 - Interpretation of Chapter

Current through July 13, 2024
(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.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-1 - Authority

Current through July 13, 2024
This Chapter is promulgated by the Department of Health
				  pursuant to the Wyoming Medical Assistance and Services Act at Wyoming Statutes
				  §§
									
										42-4-101
				  through -121.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter has been adopted to
				establish the standards and procedures for the provision of and payment for
				pharmaceutical services under Medicaid. It shall apply to all pharmaceutical
				services provided on or after the effective date of this rule.
(b) The Department may issue manuals and
				bulletins 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.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-4 - Provider Participation

Current through July 13, 2024
(a) Compliance with Chapter 3. An individual
				or entity that wishes to receive Medicaid funds for pharmaceutical services
				furnished to a client shall meet the requirements of Chapter 3 of the Wyoming
				Medicaid Rules.
(b) Eligible
				pharmaceutical services providers include non-excluded
(i) Pharmacies;
(ii) Pharmacists; and
(iii) Physicians who practice in a local
				trade area where pharmacy services are not available from a pharmacy or
				pharmacist and are enrolled as a Medicaid pharmacy services provider. Except as
				otherwise specified in this Chapter, such a physician shall meet the standards
				and follow the procedures established for a pharmacist
				provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-5 - Provider Records

Current through July 13, 2024
(a) Compliance with Chapter 3. A provider of
				pharmaceutical services shall comply with the record-keeping requirements of
				Chapter 3 of the Wyoming Medicaid Rules.
(b) Additional requirements. In addition to
				the requirements of Chapter 3, providers of pharmaceutical services shall
				retain records that include:
(i) Invoices for
				drugs;
(A) Pharmacies shall be able to supply
				all drug invoices in the format requested by the Department. This format may
				include, but is not limited to, paper, electronic, or a format generated and
				sent by wholesaler.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-7 - DUR Requirements

Current through July 13, 2024
A provider of pharmaceutical services shall comply with the
				  Drug Utilization Review (DUR) requirements of 42 C.F.R. Part 456 and Chapter 9
				  of the Board of Pharmacy Rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-8 - Covered Services

Current through July 13, 2024
(a) Prescription drugs. Prescription drugs
				are covered in the quantity prescribed by a practitioner, subject to the
				dispensing limitations of Section
				9 and the exclusions of Section
				11.
(b) Refill of prescription. In addition to
				the criteria specified in subsection (a), a refill of a prescription shall:
(i) Be authorized by the practitioner who
				originally prescribed the drug;
(ii) Conform to State and Federal laws
				governing prescription refills; and
(iii) Be within one (1) year of the date of
				the original prescription.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-9 - Dispensing Limitations

Current through July 13, 2024
(a) Generic drugs. Practitioners shall
				prescribe generic drugs except in the following circumstances:
(i) When a brand name drug is medically
				necessary and the appropriate prior authorization criteria has been
				met,
(ii) When there is not an AB
				rated generic available, or
(iii)
				When the brand name drug is listed on the Department's preferred drug list as
				preferred instead of the generic.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-10 - Relationship to Other Programs

Current through July 13, 2024
(a) This Chapter does not limit the services
				available to clients under age twenty-one (21) pursuant to Chapter 6 of the
				Wyoming Medicaid Rules.
(b) This
				Chapter does not affect services available pursuant to Chapter 29 of the
				Wyoming Medicaid Rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-11 - Excluded Services

Current through July 13, 2024
The following prescription drugs are excluded:
(a) Anorexiants, except Amphetamines and
				derivatives which are prescribed for narcolepsy and hyperkinetic
				conditions;
(b) Fertility
				drugs;
(c) Hair growth
				products;
(d) Weight gain agents,
				including androgenic or anabolic steroid agents when used for weight
				gain;
(e) Cosmetic agents such as
				Retin-A, provided to clients age twenty-one (21) years or over;
(f) OTC drugs and medical supplies, except as
				designated in Section
				8(e) of this
				Chapter;
(g) DESI drugs;
(h) Drugs supplied by a manufacturer that has
				not entered into and does not have in effect a rebate agreement which meets the
				requirements of 42 U.S.C.
				§
										1396r-8, including any amendments or
				updates, except as otherwise specified by that Section; and
(i) Any services and supplies included in the
				per diem which are furnished to a resident of a nursing home, an individual
				admitted as an inpatient or an outpatient in a hospital, or an individual in a
				swing bed.
(j) Any drug, supply or
				service not designated as a covered service under this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-12 - Pharmacy and Therapeutics (P&T) Committee

Current through July 13, 2024
(a) Pharmacy Services shall have a P&T
				Committee to meet the DUR requirements designated in Section
				7 of this Chapter. The P&T Committee
				shall be made up as follows:
(i) At least one
				third (1/3), but not more than fifty-one percent (51%) physicians;
(ii) At least one third (1/3), but not more
				than fifty-one (51%) pharmacists; and
(iii) At least one physician's assistant or
				nurse practitioner.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-13 - Prior Authorization

Current through July 13, 2024
(a) Procedures. A provider seeking
				reimbursement for services which require prior authorization shall request
				prior authorization pursuant to the procedures and in the format specified by
				the Department and disseminated to providers through manuals or bulletins.
(i) Criteria for review. Prior authorization
				shall be granted if the proposed services:
(A) Are covered services;
(B) Are consistent with the client's
				diagnosis;
(C) Are medically
				necessary;
(D) Are
				cost-effective;
(E) Meet the
				criteria established by the rules of the Department; and
(F) Are not reimbursable by any third party
				payer.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-14 - Copayment

Current through July 13, 2024
(a) Clients shall pay a three dollar and
				sixty-five cent ($3.65) per prescription copayment for Brand Name drugs, or a
				sixty-five cent ($0.65) per prescription copayment for multiple source drugs,
				except as specified in subsection (b).
(b) Exemptions. The following clients and
				pharmaceutical services are exempt from the copayment requirement:
(i) Residents of a nursing facility or swing
				beds;
(ii) Family planning
				products;
(iii) Pregnant
				clients;
(iv) Clients under age
				twenty-one (21) years;
(v) American
				Indians and Alaska Natives;
(vi)
				Emergency Services;
(vii) Hospice
				Services; and
(viii) Vaccine
				products administered in the pharmacy.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-15 - Preferred Drug List

Current through July 13, 2024
(a) A service may be placed on the Preferred
				Drug List if the service:
(i) Is a covered
				service;
(ii) Is cost-effective;
				and
(iii) Has been reviewed by the
				P&T Committee.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-16 - Medicaid Allowable Payment

Current through July 13, 2024
(a) Reimbursement Limits. Except as specified
				in subsection (b) of this section, the Medicaid allowable payment for
				pharmaceutical services shall be of the calculation below with the lowest
				reimbursement:
(i) The National Average Drug
				Acquisition Cost (NADAC) of the ingredient(s) plus the dispensing fee specified
				in subsection (d);
(ii) When no
				NADAC is available, Medicaid shall substitute Wholesale Acquisition Cost (WAC)
				+ 0% plus the dispensing fee specified in subsection (d);
(iii) When neither NADAC nor WAC are
				available, Medicaid shall substitute Average Wholesale Price (AWP) - 11% plus
				the dispensing fee specified in subsection (d);
(iv) The Federal Upper Limit (FUL) plus the
				dispensing fee specified in subsection (d);
(v) The Department set maximum allowable cost
				for specified drugs or drug categories plus the dispensing fee specified in
				subsection (d);
(vi) The ingredient
				cost submitted by the pharmacy on the claim plus the dispensing fee specified
				in subsection (d);
(vii) The gross
				amount due; or
(viii) The
				provider's usual and customary charge.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-22 - Interpretation of Chapter

Current through July 13, 2024
(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.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 10 - PHARMACEUTICAL SERVICES › Section 10-25 - 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 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 subsection (b) of this section; and
(iii) The incorporated code, standard, rule,
				or regulation is maintained at the Department and is available for public
				inspection and copying at cost at the same location.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-1 - Authority

Current through July 13, 2024
The Wyoming Department of Health (Department) promulgates
				  this Chapter pursuant to the Wyoming Medical Assistance and Services Act at
				  Wyoming Statute
										42-4-101 through
				  -124.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-2 - Purpose and Applicability

Current through July 13, 2024
(a) The Department adopts this Chapter to
				govern the standards and procedures for the provision of, and payment for,
				Medicaid medical supplies, durable medical equipment, orthotics and prosthetics
				by enrolled providers and suppliers.
(b) This Chapter applies to all clients and
				providers of any furnished Medicaid medical supplies, durable medical
				equipment, orthotics, or prosthetics.
(c) The Department may issue manuals and
				bulletins to interpret this Chapter. Such manuals and bulletins shall be
				consistent with and reflect the rules contained in 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 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-3 - Definitions

Current through July 13, 2024
(a) Except as otherwise specified in Wyoming
				Medicaid Rules Chapter 1, or as defined herein, the terminology used in this
				Chapter is the standard terminology and has the standard meaning used in health
				care, Medicaid, and Medicare.
(b)
				"Certification of medical necessity" means a written certification by the
				prescribing practitioner certifying that the equipment is medically necessary,
				as required for certain items identified by the Department.
(c) "Misuse" means the intentional
				utilization of equipment, prosthetic device, or supplies in a manner not
				prescribed or recommended resulting in the need for repairs or replacement, or
				the utilization by persons other than the client for whom the use is prescribed
				or intended according to Department records.
(d) "Practitioner's order" means a written
				order on the practitioner's personalized prescription pad or letterhead that
				contains the practitioner's printed name, the practitioner's personal
				physically-made signature, and the date it was signed.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-4 - Provider Enrollment and Participation

Current through July 13, 2024
(a) No provider or supplier of medical
				supplies, durable medical equipment, or prosthetics furnished to a client shall
				receive Medicaid reimbursement unless enrolled with Medicaid pursuant to
				Wyoming Medicaid Rules Chapter 3.
(b) A provider or supplier of medical
				supplies, durable medical equipment, or prosthetics furnished to a client shall
				meet the provider participation requirements of Wyoming Medicaid Rule Chapter
				3.
(c) A provider or provider
				entity shall provide proof of Medicare certification as a durable medical
				equipment, prosthetics, orthotics, and supplies (DMPOS) supplier prior to
				Medicaid reimbursement.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-5 - Eligible providers

Current through July 13, 2024
(a) A pharmacy;
(b) A practitioner's office;
(c) A non-pharmacy supplier with a current,
				valid business license as required by the laws of the State of Wyoming or the
				state where the business is located.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-6 - Provider records

Current through July 13, 2024
(a) A provider of medical supplies, durable
				medical equipment, or prosthetics must comply with the record-keeping
				requirements of Wyoming Medicaid Rules Chapter 3.
(b) The provider's medical records must
				substantiate the medical necessity of the medical supplies, durable equipment,
				or prosthetics prescribed for a client, including: the client's diagnosis and
				prognosis; the estimated duration of the condition which necessitates the
				medical supplies or durable medical equipment; the nature and extent of the
				client's functional limitations; other therapeutic interventions which have
				been tried and their results; and a copy of the certification of medical
				necessity, and request for prior authorization, if applicable.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-7 - Verification of Client Data

Current through July 13, 2024
A provider of medical supplies must comply with the
				  verification of client data requirements of Wyoming Medicaid Rules Chapter
				  3.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-8 - General Coverage Provisions

Current through July 13, 2024
(a) The medical supplies, durable medical
				equipment, and prosthetics described in Sections
				9 and
				10 are a covered service if they are:
(i) Medically necessary, as defined in
				Wyoming Medicaid Rules Chapter 1;
(ii) Appropriate and effective for the
				client's medical needs;
(iii)
				Timely, considering the nature and present medical condition of the
				client;
(iv) Provided by a provider
				with appropriate credential;
(v)
				The least expensive, appropriate alternative available;
(vi) Not considered experimental or
				investigational;
(vii) An effective
				and appropriate use of Medicaid funds;
(viii) Suitable for use in the client's home
				or any non-institutional setting in which normal life activities take
				place;
(ix) Generally not useful in
				the absence of an illness, injury, or disability;
(x) Provided to correct or accommodate a
				physiological disorder of physical condition, or generally used primarily for a
				medical purpose; and,
(xi)
				Prescribed using a practitioner's order which:
(A) Includes one or more diagnosis codes, or
				a statement of the condition which necessitates the medical supplies, durable
				medical equipment or prosthetics, and an estimate in days, months, or years of
				the time it will be needed;
(B) If
				durable medical equipment or a prosthetic device, specifies the additional or
				optional features which will be separately billed using HCPCS codes;
(C) If medical supplies, specifies the
				quantity and frequency of use, the frequency of changes, the estimated duration
				of medical necessity, and is reviewed and re-signed by the practitioner at
				least once per year.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-9 - Covered services

Current through July 13, 2024
(a) The following items are covered services
				if provided in compliance with the general requirements of Section
				8:
(i)
				Ambulation devices;
(ii) Lactation
				equipment and supplies;
(iii)
				Diabetic Supplies, other than insulin and insulin syringes, which may be
				covered pursuant to Medicaid Rules Chapter 10;
(iv) Enteral and Parenteral Nutrition - other
				Medical foods;
(v) Home infusion
				supplies;
(vi) Hospital beds and
				equipment;
(vii) Infusion pumps and
				supplies;
(viii) Medication
				Dispensers or equipment;
(ix)
				Orthopedic devices;
(x) Ostomy care
				products;
(xi) Oxygen delivery
				systems and supplies;
(xii)
				Pacemaker monitors, self-contained;
(xiii) Paraffin or Sitz baths;
(xiv) Phototherapy light and
				supplies;
(xv) Pneumatic
				compressors and appliances;
(xvi)
				Post-surgery recovery equipment or wound care;
(xvii) Prosthetics;
(xviii) Respiratory care accessories,
				supplies, and related devices;
(xix) Speech generating devices;
(xx) Stockings and elastic
				supports;
(xxi) Suction
				pumps;
(xxii) Syringes and
				needles;
(xxiii) Traction
				equipment;
(xxiv) Transfer or lift
				equipment;
(xxv) Transcutaneous or
				neuromuscular electrical nerve simulators;
(xxvi) Urinary care products;
(xxvii) Wheelchairs and scooters;
				and
(xxviii) Other medical
				equipment and supplies determined to be medically necessary and approved by the
				Department.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-10 - Authorization Requests for Non-Covered Services

Current through July 13, 2024
(a) Authorization may be requested for any
				piece of durable medical equipment, supply, or prosthetic that is considered a
				non-covered item as described in the Medicaid Durable Medical Equipment Manual.
				Documentation must be submitted that demonstrates the item meets the criteria
				listed in Section
				8(a).
(b) Fully completed requests shall be acted
				upon within 30 days of receipt. Wyoming Medicaid shall notify providers and
				clients of the grant or denial of the request for coverage. If denied, clients
				shall be notified of their right to request an administrative hearing pursuant
				to Wyoming Medicaid Rules Chapter 4.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-11 - Prior authorization

Current through July 13, 2024
(a) The Department may designate medical
				supplies or durable medical equipment that require prior authorization. The
				failure to obtain prior authorization shall result in denial of Medicaid
				payment for the service. Prior authorization of medical supplies and durable
				medical equipment shall be governed by the prior authorization requirements of
				Wyoming Medicaid Rules Chapter 3.
(b) In designating medical supplies or
				durable medical equipment that require prior authorization, the Department
				shall consider the:
(i) Cost of the
				service;
(ii) Potential for
				over-utilization of the medical supplies; and
(iii) Availability of lower cost
				alternatives.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-12 - Medicaid allowable payment

Current through July 13, 2024
The Medicaid allowable payment for medical supplies, durable
				  medical equipment, and prosthetics shall be pursuant to the Medicaid fee
				  schedule.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-14 - Third-party liability

Current through July 13, 2024
(a) Claims for which third-party liability
				exists shall be submitted in accordance with Wyoming Medicaid Rules Chapter
				35.
(b) 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.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS › Section 11-16 - Overpayments

Current through July 13, 2024
The Department shall recover overpayments pursuant to 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 Medicaid Fraud Control Unit at any time.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-1 - 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 Statutes
				  §§
									
										42-4-101
				  through -306
.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-2 - Purposes and Applicability

Current through July 13, 2024
(a) This Chapter establishes the scope of the
				home health services covered by Medicaid and the methods and standards of
				reimbursing providers for such services.
(b) The Department may issue Provider Manuals
				and Provider Bulletins to providers or other affected parties to interpret the
				provisions of this Chapter. Such Provider Manuals or 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.
(c) The requirements of Title XIX of the
				Social Security Act, 42 C.F.R., Chapter IV, Subchapter C, Part 440, Subpart A
				applies to this Chapter.
(d)
				Wyoming's Medicaid State Plan applies to this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-3 - 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 subsection (b) of 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.