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 3-13 - Submission of Claims

Current through July 13, 2024
(a) The Department shall deny claims which
				are improperly submitted or which contain errors of any kind. Such claims may
				be resubmitted, subject to applicable federal and state requirements.
(b) A provider shall not bill the Department
				in excess of the provider's usual and customary charge for the service. The
				provider shall not bill the client or the Department for administrative fees
				such as standard processing or late fees.
(c) An individual provider shall not submit
				claims for reimbursement unless the services were rendered personally by that
				provider, or by an intern or resident while acting under the clinical
				supervision of that provider when allowed by applicable licensing or
				credentialing bodies. A provider entity shall not submit claims for
				reimbursement unless the services were rendered by qualified employed or
				contracted personnel acting under the supervision and control of the provider
				entity.
(d) A provider may seek
				Medicaid payment through a business agent for services furnished to a client by
				the provider if the business agent's compensation is related to the actual cost
				of processing the billing, is not related on a percentage or other basis to the
				amount of the claim, and is not dependent upon payment of the claim.
(e) A provider is responsible for all claims,
				whether submitted directly or through an agent, designee, employee or other
				intermediary.
(f) Any loss of
				Medicaid reimbursement caused by provider error is the responsibility of the
				provider and the provider may not bill the client for such services.
(g) A provider shall complete all required
				documentation, including required signatures, prior to claims submission to the
				Department. Documentation prepared or completed after the submission of the
				claim may be deemed by the Department or its designee as insufficient to
				substantiate the claim, in which case Medicaid funds shall be withheld or
				recovered.
(i) Claims shall be submitted to
				the Department in the manner and on the forms specified by the
				Department.
(ii) Claims shall
				include prior authorization number, if applicable, and
(iii) Claims shall include other
				documentation or records as the Department may request as outlined in the
				applicable Medicaid provider manual.
(iv) Claims submitted to the Department for
				standard processing, among other requirements shall include:
(A) Valid client identification (ID) number
				for the client of service;
(B)
				Valid provider NPI number and taxonomy for the service provided, including
				specification of the rendering provider as applicable;
(C) Valid billing and diagnosis codes as
				established by the Department;
(D)
				Appropriate billing code units as established by the Department; and,
(E) Other provider or specific claim fields
				as required for a "clean claim" by the Department.
(v) Any paid claim that does not meet the
				claims submission criteria established by the Department will be voided after
				appropriate provider notification. "Claim voids" conducted under this authority
				shall not be subject to reconsideration or the administrative hearing process
				described in Wyoming Medicaid Rules Chapter 4.
(vi) The Department shall deny claims not
				timely submitted. Claims shall be submitted and finalized on or before twelve
				(12) months after the date of service or the date of discharge, whichever is
				later, except for the following:
(A) Medicare
				cross-over claims shall be submitted within six (6) months after the date
				Medicare acts on the claim; or
(B)
				In the event of retroactive eligibility, such claims shall be submitted within
				six (6) months of the date of the determination of retroactive
				eligibility.