Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 1 - DEFINITIONS › Section 1-3 - Definitions

Current through July 13, 2024
(a) Except as otherwise specified, the
				terminology used in this Chapter is the standard terminology and has the
				standard meaning used in healthcare, Medicaid, and Medicare.
(b) For the purpose of these rules and
				regulations, the following definitions shall apply:
(i) "Abuse." A pattern of practice by a
				provider or a client that results in healthcare utilization which is
				inconsistent with sound fiscal, business, or medical practices, and results in
				unnecessary costs to Medicaid, or in payment for services that are not
				medically necessary or that fail to meet professionally recognized standards
				for healthcare. Abuse is characterized by, but not limited to, any one of the
				following:
(A) The repeated submission of
				claims by a provider from which documentation of required material information
				is missing, incorrect or not provided for review when requested. Examples
				include, but are not limited to: incorrect or missing procedure or diagnosis
				codes, missing or invalid signatures, invalid prescription documentation,
				incorrect mathematical entries, incorrect third party liability information, or
				the incorrect use of procedure code modifiers;
(B) The repeated submission of claims by a
				provider presenting procedure codes which overstate the level or amount of
				services provided (i.e., upcoding);
(C) The repeated submission of claims by a
				provider for services which are not reimbursable under Medicaid, or the
				repeated submission of duplicate claims;
(D) Failure by a provider to develop and
				maintain legible medical records which document the nature, extent and evidence
				of the medical necessity of services provided;
(E) Failure of a provider to use generally
				accepted accounting principles or other accounting methods which relate entries
				on the medical record to entries on the claim;
(F) Excessive or inappropriate patterns of
				referral;
(G) The repeated
				submission of claims by a provider for services which were not medically
				necessary;
(H) The repeated
				submission of claims by a provider for services which exceed that requested or
				agreed to by the client or the client's responsible relative or
				guardian;
(I) The submission of
				claims for services not medically necessary under the generally accepted
				practice of provider's of such services;
(J) Overprescribing or misprescribing
				products or services;
(K) The
				repeated submission of claims by a provider without complying with the
				provisions of these rules;
(L) A
				client permitting the use of the client's Medicaid identification by any
				unauthorized individual for the purpose of obtaining services;
(M) A client obtaining services which are not
				medically necessary for the purpose of resale or for the use of a
				non-client;
(N) A client obtaining
				duplicate services from more than one (1) provider for the same medical
				condition, other than confirmation of a diagnosis, evaluation or assessment;
				or
(O) Misuse, which with respect
				to a client means the request for or utilization of services that are
				inappropriate and with respect to a provider means the furnishing of services
				that are inappropriate, or the submission of claims that do not accurately
				reflect the services provided.