reglab/statecodes huggingface dataset:
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-4 - Definitions

Current through July 13, 2024
Except as defined in this Section or as defined in Chapter 1,
				  the terminology used in this Chapter is the standard terminology and has the
				  standard meaning used in accounting, health care, Medicaid, and
				  Medicare.
(a) "Attending physician"
				means t he physician who prescribes home health services or reviews and
				certifies the plan of treatment.
(b) "Encounter" means a single episode of
				care on a date of service during which all ordered services are provided,
				regardless of length of time, except those that cannot be provided at the time
				due to medical necessity or specific physician orders to frequency or
				scheduling, i.e. services ordered "every 12 hours" or "3 times a
				day".
(c) "Home health agency"
				means a home health agency as defined by
				42 C.F.R. §
										440.70.
(d) "Home health aide" means a person that is
				certified as a nursing assistant/nurse aide by the Wyoming State Board of
				Nursing, and employed by a home health agency.
(e) "Home health aide service" means a
				covered service provided pursuant to a plan of treatment by a home health aide
				under the supervision of a registered nurse.
(f) "Intermittent" means three or fewer
				encounters per day for home health aide services and skilled nursing services
				combined.
(g) "Long-term custodial
				care" means care that has moved beyond the acute phase (has become clinically
				stable) and is expected to be needed for the rest of the client's
				life.
(h) "Plan of treatment" means
				a written treatment plan prepared on CMS Form 485 (or such other form as may be
				designated by the Department), which is signed and dated by the client's
				attending physician, and which specifies the:
(i) Client's diagnosis;
(ii) Objectives of the plan;
(iii) Client's prognosis;
(iv) Covered services which are medically
				necessary for the implementation of the plan; and
(v) Person or persons to provide such
				services or supplies.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-5 - Provider Participation

Current through July 13, 2024
(a) Payments only to providers. No provider
				that furnishes home health services to a client shall receive Medicaid funds
				unless the provider is enrolled.
(b) Compliance with Chapter 3. A provider
				that wishes to receive Medicaid reimbursement for home health services
				furnished to a client shall meet the requirements of Chapter 3.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-6 - Covered Services

Current through July 13, 2024
(a) The services and supplies specified in
				subsection (b) shall be covered services if the services are:
(i) Intermittent;
(ii) Medically necessary;
(iii) Ordered by a physician;
(iv) Documented in a plan of treatment;
				and
(v) Expected to last six (6)
				months or less.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-7 - Excluded Services

Current through July 13, 2024
(a) The following shall not be covered
				services:
(i) Long-term custodial
				care;
(ii) Homemaker
				services;
(iii) Respite
				care;
(iv) Home delivered
				meals;
(v) Services for clients
				that are in a hospital or a nursing facility;
(vi) Services that are inappropriate in the
				client's home;
(vii) Services that
				are extensive or for long periods;
(viii) Services that are not cost
				effective;
(ix) Services where the
				desired outcome could be better and faster accomplished in another setting;
				and
(x) Services not included in
				Section 6 of this
				Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-8 - Prior Authorization

Current through July 13, 2024
(a) Prior authorization of home health
				services shall be governed by Chapter 3.
(b) All home health services require prior
				authorization.
(c) The failure to
				obtain prior authorization shall result in the denial of Medicaid payment for
				the service.
(d) The provider shall
				submit the following as part of the prior authorization request.
(i) Submission of plan of treatment. The
				provider shall submit a written request for prior authorization on the forms
				specified by the Department, including the plan of treatment, before the
				submission of a claim for such services. The Department may request additional
				information as necessary to review the plan of treatment.
(A) The plan of treatment shall include a
				statement that the home health services are appropriate and medically
				necessary.
(B) The plan of
				treatment shall be reviewed, signed, and dated by the attending physician at
				least once every sixty (60) days.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-10 - Payment of Claims

Current through July 13, 2024
(a) Payment of claims shall be pursuant to
				Chapter 3.
(b) Providers shall bill
				each date of service on a separate line of the claim. Span billing is not
				allowed.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-12 - Reconsideration or Administrative Hearing

Current through July 13, 2024
(a) A provider may request that the
				Department reconsider a decision to recover overpayments. The request for
				reconsideration, the reconsideration and any administrative hearing shall be
				pursuant to the provisions of Chapters 16 and 4.
(b) A client may request an administrative
				hearing pursuant to Chapter 4 regarding the denial of any services or
				supplies.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 12 - HOME HEALTH SERVICES › Section 12-13 - 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 12 - HOME HEALTH SERVICES › Section 12-14 - Superseding Effect

Current through July 13, 2024
When promulgated, this Chapter supersedes all prior rules or
				  policy statements issued by the Department, including provider manuals and
				  provider bulletins, which are inconsistent with this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 13 - BEHAVIORAL HEALTH SERVICES › Section 13-1 - 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 13 - BEHAVIORAL HEALTH SERVICES › Section 13-2 - Purpose and Applicability

Current through July 13, 2024
(a) The Department adopts this Chapter to
				establish the scope of behavioral health services, such as mental health and
				substance use treatment services, covered by Medicaid provided by community
				mental health centers, substance abuse treatment centers, and specific
				certified and licensed providers, including the payment and submission of
				claims by providers of such services.
(b) This Chapter applies to all clients and
				providers for all furnished Medicaid behavioral health services.
(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 13 - BEHAVIORAL HEALTH SERVICES › Section 13-3 - 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
				behavioral health care, Medicaid, and Medicare.
(b) "Applied Behavior Analysis (ABA)
				Treatment" means behavior analysis services provided to children between the
				ages of 0-20 years of age with a diagnosis of Autism Spectrum Disorder in order
				to improve social, communication, and learning skills.
(c) "Behavior analysis" means the design,
				implementation and evaluation of the instructional and environmental
				modifications based on scientific research and direct and indirect observation
				and measurement of behavior and environment to produce socially significant
				improvements in human behavior. It includes the empirical identification of
				functional relations between behavior and environmental factors. It does not
				include psychotherapy, cognitive therapy, psychoanalysis, hypnotherapy,
				counseling, psychological testing, personality, intellectual or
				neuropsychological assessments or the diagnosis of psychological
				disorders.
(d) "Certified center"
				means a community mental health or substance abuse treatment center that is
				certified by the Wyoming Department of Health, Division of Behavioral
				Health.
(e) "Clinical Professional"
				means an individual who is licensed as a:
(i)
				Licensed Addictions Therapist;
(ii)
				Licensed Advanced Practitioner of Nursing with a specialty area of
				psychiatric/mental health (APRN);
(iii) Licensed Clinical Social
				Worker;
(iv) Licensed Marriage and
				Family Therapist;
(v) Licensed
				Physician;
(vi) Licensed
				Professional Counselor;
(vii)
				Licensed Psychiatric Nurse (Master level);
(viii) Licensed Psychologist;
(ix) Licensed Board Certified Behavior
				Analyst - Doctoral (BCBA-D), as defined by the Behavior Analyst Certification
				Board and the Wyoming Board of Psychology (W.S.
				33-27-124 and
				33-27-125); or
(x) Licensed Board Certified Behavior Analyst
				(BCBA), as defined by the Behavior Analyst Certification Board and the Wyoming
				Board of Psychology (W.S. 33-27-124 and
				33-27-125).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 13 - BEHAVIORAL HEALTH SERVICES › Section 13-4 - Provider Participation

Current through July 13, 2024
(a) No certified center, licensed
				psychologist, licensed APRN, licensed mental health professional, or licensed
				behavioral analyst that furnishes services to a client shall receive Medicaid
				reimbursement unless enrolled with Medicaid.
(b) A certified center, licensed
				psychologist, licensed APRN, licensed mental health professional, or licensed
				behavioral analyst that wishes to receive Medicaid reimbursement for services
				furnished to a client shall meet the provider participation requirements of
				Medicaid Rules Chapter 3.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 13 - BEHAVIORAL HEALTH SERVICES › Section 13-5 - Special Requirements for Certified Center Services

Current through July 13, 2024
(a) To receive Medicaid reimbursement, a
				certified center shall:
(i) Meet Medicaid
				enrollment requirements pursuant to Medicaid Rules Chapter 3; and
(ii) If a community mental health center, be
				under contract with the Wyoming Department of Health, Division of Behavioral
				Health as a certified center;
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 13 - BEHAVIORAL HEALTH SERVICES › Section 13-6 - Covered Services

Current through July 13, 2024
(a) Covered services shall be:
(i) Furnished to a client or collateral
				contact for the direct and exclusive benefit of the client;
(ii) Furnished by a clinical professional or
				clinical staff member who meets the requirements of the specific service and
				who practices within the scope of their license or certification.
(iii) Furnished pursuant to a treatment plan,
				updated and signed by a clinical professional at least every ninety (90) days.
				Unless the service is an initial clinical assessment, the treatment plan shall
				list the type, frequency, and duration of each service provided.
(iv) Documented by providing a legible
				progress note in the client's medical record. Each progress note shall contain
				a hand-written or electronic signature and credentials of the provider and
				shall specify:
(A) Service type and setting
				(if outside of the office);
(B)
				Begin and end times (Military or Standard Time); and
(C) Client progress towards goals identified
				in their current treatment plan; and
(v) Rehabilitative and medically
				necessary.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 13 - BEHAVIORAL HEALTH SERVICES › Section 13-7 - Service Limitations

Current through July 13, 2024
(a) Medicaid reimbursement for rehabilitative
				services shall be limited to thirty (30) visits per calendar year, unless
				pre-approved based on a determination that additional services are medically
				necessary.
(b) Habilitative
				services are not covered for clients twenty-one (21) years of age or
				older.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 13 - BEHAVIORAL HEALTH SERVICES › Section 13-8 - Excluded Services

Current through July 13, 2024
(a) The following services are excluded:
(i) Clinical services which are not provided
				in person or via a telehealth modality, other than collateral contacts
				necessary to develop or implement a treatment plan;
(ii) Education, public education, public
				relations, and speaking engagements;
(iii) Day care;
(iv) Driving while under the influence (DUI)
				classes;
(v) Missed
				appointments;
(vi) Psychological
				testing done for the sole purpose of education diagnosis, school or institution
				admission or placement or Medicaid waiver eligibility assessments;
(vii) Record-keeping time, unless allowed by
				a specific service code;
(viii)
				Recreation and socialization without an active clinical treatment component as
				specified in the individual client's treatment plan;
(ix) Remedial or other formal
				education;
(x) Residential room,
				board, or care;
(xi) Substance
				abuse or mental health disorder prevention services;
(xii) Support groups, such as Alcoholics
				Anonymous or Narcotics Anonymous;
(xiii) Time spent preparing records or
				reports, except for up to three (3) hours for a licensed psychologist to
				prepare a formal report of test findings;
(xiv) Vocational services;
(xv) Services provided to a client with:
A. Sole Diagnostic and Statistical Manual
				(DSM) diagnosis of intellectual or cognitive disability;
B. DSM diagnosis of factitious disorder;
				or
C. DSM diagnosis of any ICD-10
				"Z" code, unless the client's medical record contains a written statement
				signed by the affiliated clinical professional explaining why the treatment of
				a condition that is not classified as a mental disorder is medically
				necessary;
(xvi)
				Services provided by a school psychologist, except when provided pursuant to
				Medicaid Rules Chapter 52 School Based Services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 13 - BEHAVIORAL HEALTH SERVICES › Section 13-9 - Limited Services for Nursing Home Residents

Current through July 13, 2024
(a) Medicaid reimbursement for services
				provided to a client in a nursing facility is limited to:
(i) Clinical assessment;
(ii) Community-based individual and family
				therapy; and
(iii) Group
				therapy.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 13 - BEHAVIORAL HEALTH SERVICES › Section 13-10 - Prior Authorization

Current through July 13, 2024
The Department may designate behavioral health services, such
				  as mental health services, and substance use treatment services 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 equipment shall be governed by the prior authorization
				  requirements of Medicaid Rules Chapter 3.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 13 - BEHAVIORAL HEALTH SERVICES › Section 13-11 - Medicaid Allowable Payment

Current through July 13, 2024
(a) The Department shall establish and
				maintain payment rates for behavioral health 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 13 - BEHAVIORAL HEALTH SERVICES › Section 13-13 - Third Party Liability

Current through July 13, 2024
(a) Claims subject to third party liability
				shall be submitted in accordance with 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 13 - BEHAVIORAL HEALTH SERVICES › Section 13-15 - Overpayments

Current through July 13, 2024
The Department shall recover overpayments pursuant to
				  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 15 - AMBULANCE SERVICES › Section 15-1 - 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 15 - AMBULANCE SERVICES › Section 15-3 - 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.
(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.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 15 - AMBULANCE SERVICES › Section 15-4 - General Terms

Current through July 13, 2024
(a) The Department may issue manuals,
				bulletins, or both to interpret the provisions of this rule. Such manuals and
				bulletins shall be consistent with and reflect the administrative
				interpretations contained in this rule.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 15 - AMBULANCE SERVICES › Section 15-5 - Definitions

Current through July 13, 2024
Except as otherwise specified in Wyoming Medicaid Rule,
				  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 15 - AMBULANCE SERVICES › Section 15-6 - Provider Participation

Current through July 13, 2024
(a) Eligible providers. In order to be an
				eligible provider under this Chapter, an individual or entity shall:
(i) Hold a current ambulance business license
				pursuant to the Wyoming Emergency Medical Services Act of 1977, found at
				Wyoming Statues §§
										
											33-36-101
				through 115
,
or, if the provider is located outside Wyoming,
				is licensed under applicable provisions of that state's law; and
(ii) Meet all Medicare certification
				requirements.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 15 - AMBULANCE SERVICES › Section 15-7 - Covered Services

Current through July 13, 2024
The terms in this section shall be interpreted under the
				  definitions and classifications established by the Office of Emergency Medical
				  Services Rules.
(a) Emergency ground
				ambulance transportation is a covered service.
(i) Ground ambulance is any motor vehicle
				maintained, operated or advertised for the medical care and transportation of
				patients upon any street, highway or public way, or any motor vehicle owned and
				operated on a regular basis by the State of Wyoming or any agency,
				municipality, city, town, county or political subdivision of Wyoming for
				medical care and transportation of patients upon any street, highway or public
				way.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 15 - AMBULANCE SERVICES › Section 15-8 - Excluded Services

Current through July 13, 2024
The following are not covered services:
(a) Transportation to receive services that
				are not covered services;
(b)
				No-load trips and unloaded mileage (when no patient is aboard the ambulance),
				including transportation of life-support equipment in response to an emergency
				call;
(c) Transportation of a
				client who is pronounced dead before an ambulance is called or after the
				ambulance is called but before transport;
(d) Transportation of a family member or
				friend to visit a client or consult with the client's physician or other
				provider of medical services;
(e)
				Transportation to pick up pharmaceuticals;
(f) A client's return home when ambulance
				transportation is not medically necessary, including a client's return back to
				a nursing facility;
(g)
				Transportation of a resident of a nursing facility to receive services that are
				available at the nursing facility;
(h) Air ambulance services to transport a
				client from a hospital capable of treating the client to another hospital at
				the request of the client or family;
(i) Transportation of a client in response to
				detention ordered by a court or law enforcement agency;
(j) Transportation based on a physician's
				standing orders;
(k) Stand-by
				time;
(l) Special
				attendants;
(m) Specialty Care
				Transport (SCT);
(n) Paramedic
				Intercept (PI);
(o) When a client
				can be transported by a mode other than ambulance without endangering the
				client's health, regardless of whether other transportation is available;
				and
(p) Any other service not
				included in Section
				7 of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 15 - AMBULANCE SERVICES › Section 15-9 - Prior Authorization

Current through July 13, 2024
(a) Services that require prior
				authorization.
(i) The Department may
				designate ambulance services that require prior authorization.
(ii) In designating services that require
				prior authorization, the Department shall consider the:
(A) Cost of the service;
(B) Potential for over-utilization of the
				service; and
(C) Availability of
				lower cost alternatives.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 15 - AMBULANCE SERVICES › Section 15-11 - Submission and Payment of Claims

Current through July 13, 2024
(a) An ambulance trip report shall be
				submitted with all claims. The failure to submit such a report may result in
				the denial of payment.
(i) An ambulance trip
				report is a written report, in the form and containing the information
				specified by the Department, documenting the ambulance services for which
				Medicaid reimbursement is being sought.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 15 - AMBULANCE SERVICES › Section 15-12 - Delegation of duties

Current through July 13, 2024
The Department may delegate any of its duties under this rule
				  to the HHS, any other agency of the federal, state, or local government, or a
				  private entity which is capable of performing such functions, provided that the
				  Department shall retain the authority to impose sanctions, recover
				  overpayments, or take any other final action authorized by this Chapter or
				  another Chapter within this rule.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 15 - AMBULANCE SERVICES › Section 15-13 - 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 various provisions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-1 - 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 16 - MEDICAID PROGRAM INTEGRITY › Section 16-2 - Purpose and Applicability

Current through July 13, 2024
(a) This Chapter has been adopted to govern
				the process and procedures pertaining to Medicaid Program Integrity including,
				but not limited to, the identification and investigation of suspected fraud,
				waste, or abuse of services, the recovery of overpayments, and the imposition
				adverse actions against both providers and clients.
(b) The Department may issue manuals,
				bulletins, or both, to interpret the sections of 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 the sections of this Chapter.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-3 - 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 16 - MEDICAID PROGRAM INTEGRITY › Section 16-4 - Audits

Current through July 13, 2024
(a) The Department shall be responsible for
				the detection of suspected fraud, waste, or abuse of services.
(b) The Department shall have the ability to
				conduct audits of providers or clients.
(c) The Department may audit a provider or
				client at any time, with or without prior notice.
(d) The Department may perform audits through
				employees, agents, or through a third party. Audits shall be performed in
				accordance with Generally Accepted Auditing Standards (GAAS).
(e) If at any time during an audit the
				Department discovers evidence of an overpayment, that evidence may be referred
				to the MFCU or the DFS Eligibility Integrity Unit.
(f) Provider self-audit.
(i) A provider may conduct a self-audit at
				any time. The Department may review or audit the provider's
				self-audit.
(ii) The Department may
				require a provider to conduct a self-audit at any time.
(iii) The provider shall notify the
				Department within sixty (60) business days of the completion of the
				self-audit.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-5 - Random Sample and Extrapolation

Current through July 13, 2024
(a) The Department shall notify the provider
				via certified mail of its intent to use extrapolation. The notice shall
				include:
(i) The nature of the
				claims;
(ii) The number of claims;
				and
(iii) The method to be used in
				extrapolating from the sample.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-6 - Review of All Claims Submitted by the Provider

Current through July 13, 2024
The Department may conduct a prepayment or post-payment
				  review of all claims submitted by the provider for six (6) years from the paid
				  date.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-7 - Claim Adjustments and Denials

Current through July 13, 2024
(a) The Department shall make a claim
				adjustment after Medicaid payment has been made. If there is an adjusted
				amount, the Department may recover the adjustment amount.
(b) 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.
(c) A provider may not request
				reconsideration or an administrative hearing regarding a claims
				adjustment/denial.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-8 - Repayment of Credit Balance

Current through July 13, 2024
(a) A provider shall repay any credit balance
				within thirty (30) business days after the date such credit balance is
				identified by the Department or the provider.
(b) A provider credit balance may be
				collected from the same provider under another provider number if that provider
				number is listed with the same tax identification number.
(c) If an identified credit balance is not
				timely paid to the Department, the Department may recover the
				balance.
(d) A provider may not
				request reconsideration or an administrative hearing regarding a credit
				balance.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-9 - Medicaid allowable payment

Current through July 13, 2024
(a) Any payment which exceeds the Medicaid
				allowable payment for the service shall be recovered.
(b) A provider may not request
				reconsideration or an administrative hearing regarding a recovery of payments
				which exceeds the Medicaid allowable payment.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-10 - Investigation of Suspected Fraud, Waste, or Abuse of Services by Providers

Current through July 13, 2024
(a) The Department shall be responsible for
				the detection of suspected fraud, waste, or abuse of services.
(b) The Department is authorized to
				investigate, or to refer to appropriate agencies the investigation of suspected
				fraud, waste, or abuse of services identified pursuant to this section. An
				investigation shall be for the purpose of determining if:
(i) The identified practice is lawful and in
				compliance with existing rules and regulations and state and federal
				laws;
(ii) Fraud, waste, or abuse
				of services exists and can be documented;
(iii) Sufficient evidence can be developed to
				support the recovery of overpayments, the imposition of an adverse action or
				any other civil or criminal action permitted by law; or
(iv) The matter should be referred for
				additional investigation or other action by a law enforcement agency or the
				Medicaid Fraud Control Unit (MFCU).
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-11 - Investigation of Suspected Fraud, Waste, or Abuse of Services by Clients

Current through July 13, 2024
(a) The Department is authorized to identify
				and investigate, or to refer to appropriate agencies for investigation,
				suspected fraud, waste, or abuse of services by clients identified pursuant to
				this section. An investigation shall be for the purpose of determining if:
(i) Fraud, waste, or abuse of services
				occurred or is occurring and can be documented;
(ii) Sufficient evidence can be developed to
				support restricting client participation; or
(iii) Sufficient evidence can be developed to
				support recovery of overpayments.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-12 - Adverse Actions for Providers

Current through July 13, 2024
(a) The Department may impose adverse actions
				against a provider for:
(i) Suspected or
				substantiated fraud, waste, or abuse of services in submitting
				claims;
(ii) A pattern of
				presenting false or duplicate claims or claims for services not medically
				necessary;
(iii) A pattern of
				making false statements of material facts for the purpose of obtaining
				overpayments;
(iv) Failure to
				comply with the provisions of the provider agreement;
(v) Civil Remedies imposed by Centers for
				Medicare and Medicaid Services (CMS);
(vi) Failure to render requested
				documentation;
(vii) Situations
				that pose a threat to the health, safety, or welfare of the clients or general
				public;
(viii) Suspension,
				termination, or expiration of state licensure or any certification required to
				provide services;
(ix) Lack of or
				repeated failure to provide documentation of Medicaid services;
(x) Provider's inability to repay
				overpayments;
(xi) Failure to
				maintain current contact information;
(xii) Exclusion by the Office of Inspector
				General;
(xiii)
				Termination/exclusion under Medicare, Children's Health Insurance Program
				(CHIP) or another State's Medicaid program;
(xiv) Failure to maintain records;
(xv) Refusal to grant access to
				records;
(xvi) Refusing to complete
				education;
(xvii) Pending the
				completion of an on-going investigation conducted by the MFCU or another law
				enforcement agency;
(xviii) Failure
				to notify the Department of the completion of a self-audit within sixty (60)
				days;
(xix) Prosecution by the MFCU
				or another law enforcement agency and found guilty of healthcare
				fraud;
(xx) Failure to submit any
				paid claims for over one (1) year;
(xxi) Failure to submit an acceptable
				corrective action/quality improvement plan, or has failed to implement the
				corrective action/quality improvement plan approved by the
				Department;
(xxii) The chronic
				failure to provide services pursuant to the individual plan of care;
(xxiii) Providing services that fail to meet
				the applicable standard of care for the profession/service involved;
(xxiv) There is a continuing condition
				creating serious detriment to the health, safety, or welfare of recipients of
				home and community-based waiver services; or
(xxv) Violation of Medicaid, Department, or
				other State or Federal statute, rule, or law relating to provisions of
				services.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-13 - Adverse Actions for Clients

Current through July 13, 2024
(a) The Department may impose or refer a
				client to the appropriate agency for adverse actions for instances including,
				but not limited to:
(i) Fraud, waste, or
				abuse in obtaining services;
(ii)
				Alteration or duplication of the client's Medicaid identification
				card;
(iii) Permitting, authorizing
				or assisting a non-client to use the client's Medicaid identification card to
				obtain services;
(iv) Using another
				client's Medicaid identification card to obtain services;
(v) Alteration or duplication of a
				prescription;
(vi) Knowingly
				misrepresenting material facts regarding the client's physical or mental
				condition for the purpose of obtaining services;
(vii) Knowingly furnishing incorrect
				information regarding eligibility to a provider;
(viii) Knowingly furnishing incorrect
				information to a provider to obtain services which are not medically
				necessary;
(ix) Pending the
				completion of an on-going investigation conducted by the MFCU, Eligibility
				Integrity Unit or another law enforcement agency;
(x) Refusing to complete education;
				or
(xi) Obtaining services by any
				false or incorrect pretenses.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-14 - Educational Intervention

Current through July 13, 2024
(a) If the adverse action includes
				educational intervention, the Department will inform the provider or client:
(i) The reason(s) for the educational
				intervention,
(ii) The education
				required,
(iii) The time and date
				of the education, and
(iv) That the
				continued participation as a provider or client in Medicaid is contingent on
				complete of the education by the specified date.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-15 - Recovery of Overpayments from Providers or Clients

Current through July 13, 2024
(a) The Department shall recover overpayments
				from providers. The Department may recover overpayments from a clinic, group,
				corporation, professional association, or other organization of any current or
				former member of that practice. The Department may also recover overpayments
				from an individual provider that was formerly part of a clinic, group,
				corporation, professional association or other organization. The Department
				shall recover overpayments from a client that has engaged in abuse of services,
				fraud, or waste resulting in an overpayment.
(b) After determining that a provider or
				client has received overpayments, the Department shall send written notice, via
				certified mail, return receipt requested, to the provider or client. In
				addition to any additional notice requirements, the notice shall include:
(i) The amount of the overpayments;
				and
(ii) The basis for the
				determination of overpayments.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-16 - Suspension and Termination of Provider

Current through July 13, 2024
(a) A suspension or termination under this
				section shall be the same and shall run contemporaneously with the period of
				the provider's suspension from a licensing entity, Medicare, another State
				Medicaid Agency or any period of voluntary non-participation.
(b) A suspended or terminated provider shall
				not submit any claims, either personally or through a third party payer,
				clinic, group or other association, for any services provided after the
				effective date of the suspension;
(c) No clinic, group, corporation,
				professional association or other organization shall submit any claim for
				services provided by an individual provider within such organization after the
				effective date of the individual provider's suspension or termination;
				and
(d) The Department shall not
				pay any claims submitted by a provider for services provided to a client during
				any period of suspension or after a provider has been terminated.
(e) The Department may suspend any and all
				provider numbers that have the same tax identification number as the provider
				number that has been suspended or terminated.
(f) This section does not preclude the filing
				of claims prior to a termination. Any filed claims may be held in suspense
				until a final decision is rendered on the termination.
(g) The Department may reinstate or reenroll
				a suspended or terminated provider if:
(i) The
				Department has been reimbursed for all overpayments or a payment agreement is
				in effect;
(ii) The Department is
				satisfied that sufficient safeguards have been implemented to insure that
				fraud, waste, or abuse of services, or other factors which led the suspension
				or termination, will not recur; and
(iii) For terminated providers, an approved
				new provider agreement is signed by all parties.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-17 - Conditions on Providers

Current through July 13, 2024
(a) The Department may place the following
				condition(s) on the provider's certification or Medicaid enrollment:
(i) Requiring a physician's or appropriate
				medical specialist's statement verifying the ability to perform service duties
				as required;
(ii) Restricting the
				provider's certification or participation to a specific service;
(iii) Restricting the provider's
				certification or participation to a specific geographic area or location;
				and
(iv) Requiring the provider to
				deny new admissions.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-18 - Impose a Monitor

Current through July 13, 2024
(a) The state monitor shall have access to
				all of the provider's financial and health records, service delivery settings,
				staff and participant information that is otherwise available to the
				Department.
(b) The state monitor
				shall be removed when the provider has abated the areas of non-compliance and
				has submitted and implemented an acceptable corrective action / quality
				improvement plan.
(c) The state
				shall pay the costs and expenses of the state monitor if the provider fails to
				do so. The monitor shall continue to monitor the provider until payment in full
				is received from the provider.
(d)
				The Department shall make a reasonable effort to assure that there is not a
				potential conflict of interest between the state monitor and the
				provider.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-19 - Civil Monetary Penalties

Current through July 13, 2024
(a) When determining the amount of any
				proposed penalty, the Department shall consider the following factors:
(i) The size of the provider's operation,
				including number of clients served;
(ii) The gravity and extent of any potential
				or actual health, safety, or welfare risk to a participant;
(iii) The degree of fault of the provider in
				causing or failing to correct the violation either through act or omission,
				ranging from inadvertent action causing an event which was unavoidable by the
				exercise of reasonable care to reckless, knowing, or intentional
				conduct;
(iv) Whether economic
				benefit resulted from the provider's failure to comply;
(v) The appropriateness of any action or
				inaction to mitigate a health, safety, or welfare risk to a
				participant;
(vi) The provider's
				history of previous substantiated violations; and
(vii) Any other relevant information
				submitted to the Department between the initial adverse action and the decision
				to impose civil monetary penalty.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-20 - Immediate suspensions

Current through July 13, 2024
(a) If a substantial and immediate threat to
				the health or safety of clients exists, the Department may immediately suspend
				the certification or enrollment of the provider and take action necessary to
				protect the health and safety of participants
(b) Notice of the immediate suspension shall
				be in writing provided to the provider at the time of the suspension.
(c) The provider shall be afforded an
				opportunity for a hearing within ten (10) business days after the effective
				date of the immediate suspension.
(i) A
				request for hearing shall be provided to the Department within two (2) business
				days after the receipt of notice.
(ii) The Department shall notify the provider
				that the hearing has been accepted or denied within one (1) business day of
				receipt of the request.
(iii)
				Providers shall not be afforded the opportunity to request reconsideration for
				suspensions under this section.
(iv) All other procedures for immediate
				suspension hearings shall be as specified by Chapter 4 of the Wyoming
				Department of Health's Medicaid Rules.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-21 - Reconsideration

Current through July 13, 2024
(a) Request for reconsideration.
(i) A provider may request that the
				Department reconsider an adverse action. Such request shall be mailed to the
				Department via certified mail within twenty (20) business days after the
				mailing of the notice of the adverse action.
(A) The request must state with specificity
				the reasons for the request. Failure to provide such a statement shall result
				in the dismissal of the request with prejudice.
(B) A provider shall submit any additional
				relevant information at the time of the request.
Wyoming Administrative Code › Agency 048 - Health, Department of › Sub-Agency 0037 - Medicaid › Chapter 16 - MEDICAID PROGRAM INTEGRITY › Section 16-22 - Suspending or Withholding Payments Pending Reconsideration or Administrative Hearing

Current through July 13, 2024
(a) The Department may suspend a provider or
				withhold all payments for services furnished by a provider pending
				reconsideration or administrative hearing if the State Medicaid Agent or his or
				her designee determines in writing and notifies the provider that:
(i) There is a substantial likelihood the
				Department will prevail in an action to recover overpayments;
(ii) There is a substantial likelihood the
				provider's pattern or practice which prompted the investigation will continue;
				or
(iii) There is reasonable cause
				to doubt the provider's financial ability to refund any overpayments.