CMS 1500 ICD 10 WYOMING Manual CMS1500 4 1 17

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DIVISION OF HEALTHCARE FINANCING

CMS 1500 ICD-10

April 1, 2017

General Information____________________________________________________________

CMS 1500 ii Revision 4/1/17

Overview

Thank you for your willingness to serve clients of the Medicaid Program and other

medical assistance programs administered by the Division of Healthcare Financing.

This manual supersedes all prior versions.

Rule References

Providers must be familiar with all current rules and regulations governing the

Medicaid Program. Provider manuals are to assist providers with billing Medicaid;

they do not contain all Medicaid rules and regulations. Rule citations in the text are

only a reference tool. They are not a summary of the entire rule. In the event that the

manual conflicts with a rule, the rule prevails. Wyoming State Rules may be located

at, http://soswy.state.wy.us/Rules/default.aspx.

General Information____________________________________________________________

CMS 1500 iii Revision 4/1/17

Importance of Fee Schedules and Provider’s Responsibility

Procedure codes listed in the following Sections are subject to change at any time

without prior notice. The most accurate way to verify coverage for a specific service

is to review the Medicaid fee schedules on the website (2.1, Quick Reference). Fee

schedules list Medicaid covered codes, provide clarification of indicators, such as

whether a code requires prior authorization and the number of days in which follow-

up procedures are included. Not all codes are covered by Medicaid or are allowed for

all taxonomy codes (provider types). It is the provider’s responsibility to verify this

information. Use the current fee schedule in conjunction with the more detailed

coding descriptions listed in the current CPT-4 and HCPCS Level II coding books.

Remember to use the fee schedule and coding books that pertain to the appropriate

dates of service. Wyoming Medicaid is required to comply with the coding

restrictions under the National Correct Coding Initiative (NCCI) and providers should

be familiar with the NCCI billing guidelines. NCCI information may be reviewed at

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions

may arise that require a call to a specific department such as Provider Relations or

Medical Policy (2.1, Quick Reference).

Medicaid manuals, bulletins, fee schedules, forms, and other resources are available

on the Medicaid website or by contacting Provider Relations.

General Information____________________________________________________________

CMS 1500 iv Revision 4/1/17

AUTHORITY

The Wyoming Department of Health is the single state agency appointed as required in the Code

of Federal Regulations (CFR) to comply with the Social Security Act to administer the Medicaid

Program in Wyoming. The Division of Healthcare Financing (DHCF) directly administers the

Medicaid Program in accordance with the Social Security Act, the Wyoming Medical Assistance

and Services Act, (W.S. 42-4-101 et seq.), and the Wyoming Administrative Procedure Act

(W.S. 16-3-101 et seq.). Medicaid is the name chosen by the Wyoming Department of Health for

its Medicaid Program.

This manual is intended to be a guide for providers when filing medical claims with Medicaid.

The manual is to be read and interpreted in conjunction with Federal regulations, State statutes,

administrative procedures, and Federally approved State Plan and approved amendments. This

manual does not take precedence over Federal regulation, State statutes or administrative

procedures.

General Provider Information____________________________________________________

CMS 1500 v Revision 4/1/17

Contents:

Contents: v

Chapter One – General Information .......................................................................... 1

Chapter Two – Getting Help When You Need It ...................................................... 6

Chapter Three – Provider Responsibilities ..............................................................15

Chapter Four – Utilization Review ..........................................................................32

Chapter Five – Client Eligibility ..............................................................................39

Chapter Six – Common Billing Information ...........................................................46

Chapter Seven – Third Party Liability ...................................................................112

Chapter Eight – Electronic Data Interchange (EDI) ..............................................124

Chapter Nine – Wyoming HIPAA 5010 Electronic Specifications ......................132

Chapter Ten – Important Information ....................................................................154

Chapter Eleven – Covered Services – Ambulance ................................................158

Chapter Twelve – Covered Services – Audiology.................................................166

Chapter Thirteen – Covered Services – Behavioral Health ...................................170

Chapter Fourteen – Covered Services – Children’s Mental Health Waiver .........207

Chapter Fifteen – Covered Services – Chiropractic Services ................................210

Chapter Sixteen – Covered Services – Developmental Centers ............................214

Chapter Seventeen – Covered Services – Dietician ..............................................221

Chapter Eighteen – Covered Services – DME Billing ..........................................224

Chapter Nineteen – Covered Services – Family Planning .....................................228

Chapter Twenty – Covered Services – Health Check ...........................................230

Chapter Twenty One – Covered Services – Interpreter Services ..........................245

Chapter Twenty Two – Covered Services – Laboratory Services .........................248

Chapter Twenty Three – Covered Services – Non-Emergency Medical

Transportation ........................................................................................................253

General Provider Information____________________________________________________

CMS 1500 vi Revision 4/1/17

Chapter Twenty Four – Covered Services – Practitioner Services .......................257

Chapter Twenty Five – Covered Services – Pregnant by Choice ..........................334

Chapter Twenty Six – Covered Services – Therapy Services ...............................339

Appendix 346

General Provider Information____________________________________________________

Ch. 1 Index 1 Revision 4/1/17

Chapter One – General Information

1.1 How the CMS-1500 Manual is Organized ............................................................ 1

1.2 Updating the Manual ............................................................................................. 2

1.2.1 RA Banner Notices/Samples ................................................................................. 3

1.2.2 Medicaid Bulletin Notification/Sample ................................................................. 4

1.2.3 Wyoming Department of Health (WDH) State Letter/Sample ............................. 4

1.3 State Agency Responsibilities ............................................................................... 5

1.4 Fiscal Agent Responsibilities ................................................................................ 5

General Provider Information____________________________________________________

Ch. 1 Index 1 Revision 4/1/17

1.1 How the CMS-1500 Manual is Organized

The table below provides a quick reference describing how the CMS-1500 Manual is

organized.

Chapter

Description

Two

Getting Help When You Need It – Quick Reference guide, telephone

numbers and addresses and web sites for help and training.

Three

Provider Responsibilities – Obligations and rights as a Medicaid

provider. The topics covered include enrollment changes, civil rights,

group practices, provider-patient relationship, and record keeping

requirements.

Four

Utilization Review – Fraud and abuse definitions, the review process,

and rights and responsibilities.

Five

Client Eligibility – How to verify eligibility when a client presents their

Medicaid card.

Six

Common Billing Information – Basic claim information, completing

the claim form, cap limits, co-pays, prior authorizations, timely filing,

consent forms, NDC, working the Medicaid remittance advice (RA) and

completing adjustments.

Seven

Third Party Liability (TPL)/Medicare – Explains what TPL/Medicare

is, how to bill it and exceptions to it.

Eight

Electronic Data Interchange (EDI) – Explains the advantages of

exchanging documents electronically. Secured Provider Web Portal

registration process.

Nine

Wyoming Specific HIPAA 5010 Electronic Specifications – This

chapter covers the Wyoming Specific requirements pertaining to

electronic billing. Wyoming payor number and electronic

adjustments/voids.

Ten

CMS-1500 Covered Services – This chapter is alphabetical by

professional service and provides information such as: definitions,

procedure code ranges, documentation requirements, covered and non-

covered services and billing examples.

Appendices

Appendices – Provide key information in an at-a-glance format. This

includes the Provider Manual Version Control Table, and last quarters

Provider Notifications.

General Provider Information____________________________________________________

Ch. 1 Index 2 Revision 4/1/17

1.2 Updating the Manual

When there is a change in the Medicaid Program, Medicaid will update the manuals

on a quarterly (January, April, July, and October) basis and publish them to the

Medicaid website. Most of the changes come in the form of provider bulletins (via

email) and Remittance Advice (RA) banners, although others may be newsletters or

Wyoming Department of Health letters (via email) from state officials. The updated

provider manuals will be posted to the website and will include all updates from the

previous quarter. It is in the provider’s best interest to download an updated provider

manual and keep their email addresses up-to-date. Bulletin, RA banner, newsletter

and state letter information will be posted to the website as it is sent to providers, and

will be incorporated into the provider manuals as appropriate to ensure the provider

has access to the most up to date information regarding Medicaid policies and

procedures.

RA banner notices appear on the first page of the proprietary Wyoming Medicaid

Remittance Advice (RA), which is available for download through the Secured

Provider Web Portal after each payment cycle in which the provider has claims

processed or “in process”. This same notice also appears on the RA payment

summary email that is sent out each week after payment, and is published to the

“What’s New” section of the website.

It is critical for providers to keep their contact email address(es) up-to-date to ensure

they receive all notices published by Wyoming Medicaid. It is recommended that

providers add the “wycustomersvcs@acs-inc.com” email address from which notices

are sent to their address books to avoid these emails being inadvertently sent to junk

or spam folders.

All bulletins and updates are published to the Medicaid website (2.1, Quick

Reference).

NOTE: Provider bulletins and state letter email notifications are sent to the email

addresses on-file with Medicaid and are sent in two (2) formats, plain text

and HTML. If the HTML format is received or accepted then the plain text

format is not sent.

General Provider Information____________________________________________________

Ch. 1 Index 3 Revision 4/1/17

1.2.1 RA Banner Notices/Samples

RA banners are limited in space and formatting options and are used to notify

providers quickly and often refer providers elsewhere for additional information.

Sample RA Banner:

************************************************************************

ICD-10 IMPLEMENTATION OCTOBER 1, 2015

EXPECT:

1) LONGER WAIT TIMES WHEN CALLING PROVIDER RELATIONS OR EDI SERVICES

2) INCREASED POSSIBILITY OF RECEIVING A BUSY DISCONNECT WHEN

EXITING THE IVR

3) DO NOT EXPECT THE AGENTS TO PROVIDE ICD-10 CODES

TROUBLESHOOTING TIPS PRIOR TO CALLING THE CALL CENTERS:

1) IF YOUR SOFTWARE OR VENDOR/CLEARINGHOUSE IS NOT ICD-10 READY--FREE

SOFTWARE AVAILABLE ON THE WY MEDICAID WEBSITE (CANNOT DROP TO PAPER)

2) ICD-10 DX/SURGICAL DENIALS, VERIFY FIRST: CODES ARE BOTH ALPHA & NUMERIC,

DX QUALIFIER, O VS 0, 1 VS I

3) VERIFY DOS, PRIOR TO 10/1/15 BILL WITH ICD-9 AND ON OR AFTER 10/1/15 BILL WITH

ICD-10 CODES

4) INPATIENT SERVICES THAT SPAN 9/2015-10/2015 BILL WITH ICD-10

HTTP://WYMEDICAID. ACS-INC.COM/PROVIDER_HOME.HTML

**************************************************************************

Sample RA Payment Summary (weekly email notification):

-----Original Message-----

From: Wyoming Medicaid [mailto:wycustomersvc@xerox.com]

Sent: Thursday, May 28, 2015 5:17 AM

To: Provider Email Name

Subject: Remittance Advice Payment Summary

On 05/27/2015, at 05:16, Wyoming Medicaid wrote:

Dear Provider Name,

The following is a summary of your Wyoming Medicaid remittance advice 123456 for 05/27/2015, an RA

Banner with important information may follow.

*****************************************************

RA PAYMENT SUMMARY

*****************************************************

To: Provider Name

NPI Number: 1234567890

Provider ID: 111111111

Remittance Advice Number: 123456

Amount of Check: 16,070.85

The RA banner notification will appear here when activated for the provider’s taxonomy (provider type)

General Provider Information____________________________________________________

Ch. 1 Index 4 Revision 4/1/17

1.2.2 Medicaid Bulletin Notification/Sample

Medicaid bulletin email notifications typically announce billing changes, new codes

requiring prior authorization, reminders, up and coming initiatives, etc.

Sample bulletin email notification (HTML format):

1.2.3 Wyoming Department of Health (WDH) State Letter/Sample

WDH email notifications typically announce significant Medicaid policy changes,

RAC and other audits, etc.

Sample WDH email notification (HTML format):

General Provider Information____________________________________________________

Ch. 1 Index 5 Revision 4/1/17

1.3 State Agency Responsibilities

The Division of Healthcare Financing administers the Medicaid Program for the

Department of Health. They are responsible for financial management, developing

policy, establishing benefit limitations, payment methodologies and fees, and

performing utilization review.

1.4 Fiscal Agent Responsibilities

Conduent is the fiscal agent for Medicaid. They process all claims and adjustments,

with the exception of pharmacy. They also answer provider inquiries regarding claim

status, payments, client eligibility, known third party insurance information and

provider training visits to train and assist the provider office staff on Medicaid billing

procedures or to resolve claims payment issues.

NOTE: Wyoming Medicaid is not responsible for the training of the provider’s

billing staff or to provide procedure or diagnosis codes or coding training.

Getting Help When You Need It__________________________________________________

Ch.2 Index 6 Revision 4/1/17

Chapter Two – Getting Help When You Need It

2.1 Quick Reference .................................................................................................... 7

2.2 How to Call for Help ........................................................................................... 11

2.3 How to Write for Help ......................................................................................... 11

2.3.1 Provider Inquiry Form ......................................................................................... 12

2.4 How to Get a Provider Training Visit ................................................................. 12

2.5 How to Get Help Online ...................................................................................... 13

2.6 Training Seminars/Presentations ......................................................................... 13

Getting Help When You Need It__________________________________________________

Ch.2 Index 7 Revision 4/1/17

2.1 Quick Reference

Agency Name &

Address

Telephone/Fax

Numbers

Web Address

Contact For:

Dental Services –

Interactive Voice

Response (IVR)

System

Tel (800)251-1270

24 / 7

N/A

 Payment inquiries

 Client eligibility

 Medicaid client number and

information

 Lock-in status

 Cap limits

 Medicare Buy-In data

 Service limitations

 Client third party coverage

information

NOTE: The client’s Medicaid ID

number or social security

number is required to verify

client eligibility.

Claims

PO Box 547

Cheyenne, WY

82003-0547

N/A

 Claim adjustment submissions

 Hardcopy claims submissions

 Returning Medicaid checks

Dental Service

PO Box 667

Cheyenne, WY

82003-0667

Tel (888)863-5806

9-5pm MST M-F

Fax (307)772-8405

http://wymedicaid.acs-

inc.com/

 Bulletin/manual inquiries

 Claim inquiries

 Claim submission problems

 Client eligibility

 How to complete forms

 Payment inquiries

 Request Field Representative visit

 Training seminar questions

 Timely filing inquiries

 Verifying validity of procedure

codes

 Claim void/adjustment inquiries

 WINASAP training

 Web Portal training

EDI Services

PO Box 667

Cheyenne, WY

82003-0667

Tel (800)672-4959

OPTION 3

9-5pm MST M-F

Fax (307)772-8405

http://wymedicaid.acs-

inc.com/

 EDI Enrollment Forms

 Trading Partner Agreement

 WINASAP software

 Technical support for WINASAP

 Technical support for vendors,

billing agents and clearing houses

 Web Portal registration/password

resets

 Technical support for Web Portal

ACS EDI

Gateway

N/A

http://www.acs-gcro.com

 Download WINASAP software

Getting Help When You Need It__________________________________________________

Ch.2 Index 8 Revision 4/1/17

Agency Name &

Address

Telephone/Fax

Numbers

Web Address

Contact For:

Medical Policy

PO Box 667

Cheyenne, WY

82003-0667

Tel (800)251-1268

OPTIONS 1,1,4,3

9-5pm MST M-F

(24/7 Voicemail

Available)

Fax (307)772-8405

http://wymedicaid.acs-

inc.com/manuals.html

Cap limit waiver requests

Prior authorization requests for:

 Out-of-State Home Health

 Surgeries requiring prior

authorization

 Hospice Services: Limited to clients

residing in a nursing home

Provider

Relations

PO Box 667

Cheyenne, WY

82003-0667

(IVR Navigation

Tips available on

the website)

Tel (800)251-1268

9-5pm MST M-F

(call center hours)

Fax (307)772-8405

24 / 7

(IVR availability)

http://wymedicaid.acs-

inc.com/

http://wymedicaid.acs-

inc.com/contact.html

 Provider enrollment questions

 Bulletin/Manuals inquiries

 Cap limits

 Claim inquiries

 Claim submission problems

 Client eligibility

 Claim void/adjustment inquiries

 Form completion

 Payment inquiries

 Request Field Representative visit

 Training seminar questions

 Timely filing inquiries

 Troubleshooting prior authorization

problems

 Verifying validity of procedure codes

Third Party

Liability (TPL)

PO Box 667

Cheyenne, WY

82003-0667

Tel (800)251-1268

OPTION 2

9-5pm MST M-F

Fax (307)772-8405

Select Option 2 if you

need Medicare or

estate and trust

recovery assistance

THEN

Select Option 2 if you

are with an insurance

company, attorney’s

office or child support

enforcement

Select Option 3 for

Medicare and

Medicare Premium

payments

Select Option 4 for

estate and trust

recovery inquires

N/A

 Client accident covered by liability

or casualty insurance or legal

liability is being pursued

 Estate and Trust Recovery

 Medicare Buy-In status

 Reporting client TPL

 New insurance coverage

 Policy no longer active

 Problems getting insurance

information needed to bill

 Questions or problems regarding

third party coverage or payers

 WHIPP program

Getting Help When You Need It__________________________________________________

Ch.2 Index 9 Revision 4/1/17

Agency Name &

Address

Telephone/Fax

Numbers

Web Address

Contact For:

Transportation

Services

PO Box 667

Cheyenne, WY

82003-0667

Tel (800)595-0011

9-5pm MST M-F

(24/7 Voicemail

Available)

Fax (307)772-8405

http://wymedicaid.acs-

inc.com/client/

Client inquiries:

 Prior authorize transportation

arrangements

 Request travel assistance

 Verify transportation is reimbursable

Qualis Health

DMEPOS

PO Box 33400

Seattle, WA

98133

Tel (800)783-8606

8a-6pm MST M-F

Fax (877)810-9265

http://www.qualishealth.org/

 DMEPOS Covered Services manual

 Prior authorization request for

Durable Medical Equipment (DME)

or Prosthetic/Orthotic Services

(POS)

 Questions related to documentation

or clinical criteria for DMEPOS

WYhealth

(Utilization and

Care

Management)

PO Box 49

Cheyenne, WY

82003-0049

Tel (888)545-1710

Nurse Line:

(OPTION 2)

Fax PASRRs Only

(888)245-1928

(Attn: PASRR

Processing Specialist)

http://www.WYhealth.net/

 Medicaid Incentive Programs

 Diabetes Incentive Program

 ER Utilization Program

 P4P

 SBIRT

 Educational Information about

WYhealth Programs

Prior authorization for:

 Acute Psych

 Extended Psych

 Extraordinary heavy care

 Gastric Bypass

 Inpatient rehabilitation

 Psychiatric Residential Treatment

Facility (PRTF)

 Transplants

 Vagus Nerve Stimulator

Aids Drug

Assistance

Program (ADAP)

Tel (307)777-5800

Fax (307)777-7382

N/A

1) Prescription medications

2) Program information

Maternal & Child

Health (MCH)

/Children Special

Health (CSH)

6101 N.

Yellowstone Rd.

Ste. 420

Cheyenne, WY

82002

Tel (307)777-7941

Tel (800)438-5795

Fax (307)777-7215

N/A

 High Risk Maternal

 Newborn intensive care

 Program information

Severe

Malocclusion

Tel (307)777-8088

Fax (307)777-6964

N/A

 Severe Malocclusion Applications

and Criteria

Social Security

Administration

(SSA)

Tel (800)772-1213

N/A

Social Security benefits

Medicare

Tel (800)633-4227

N/A

Medicare information

Getting Help When You Need It__________________________________________________

Ch.2 Index 10 Revision 4/1/17

Agency Name &

Address

Telephone/Fax

Numbers

Web Address

Contact For:

Division of

Healthcare

Financing

(DHCF)

6101

Yellowstone Rd.

Ste. 210

Cheyenne, WY

82002

Tel (307)777-7531

Tel (866)571-0944

Fax (307)777-6964

http://www.health.wyo.gov

/healthcarefin/index.html

 Medicaid State Rules

 State Policy and Procedures

 Concerns/Issues with state

Contractors/Vendors

DHCF Program

Integrity

6101

Yellowstone Rd.

Ste. 210

Cheyenne, WY

82002

Tel (855)846-2563

N/A

Client or Provider Fraud, Waste and

Abuse

NOTE: Callers may remain

anonymous when reporting

Stop Medicaid

Fraud

Tel (855)846-2563

http://stopmedicaidfraud.w

yo.gov

 Information and education

regarding fraud, waste, and abuse in

the Wyoming Medicaid program

 To report fraud, waste and abuse

DHCF Pharmacy

Program

6101

Yellowstone Rd.

Ste. 210

Cheyenne, WY

82002

Tel (307)777-7531

Fax (307)777-6964

N/A

General questions

Goold Health

Systems, Inc.

(GHS)

PBM Vendor

Tel (877)209-1264

(Pharmacy Help

Desk)

Tel (877)207-1126

(PA Help Desk)

http://www.wymedicaid.org/

Pharmacy prior authorization

Enrollment

Pharmacy manuals

FAQs

Customer Service

Center (CSC) ,

Wyoming

Department of

Health

2232 Dell Range

Blvd, Suite 300

Cheyenne, WY

82009

Tel (855)294-2127

TTY/TDD

(855)29-5205

(Clients Only, CSC

cannot speak to

providers)

7-6pm MST M-F

Fax (855)329-5205

www.wesystem.wyo.gov

Client Medicaid applications

Eligibility questions regarding:

1) Family and Children’s programs

2) Tuberculosis Assistance Program

3) Medicare Savings Programs

4) Employed Individuals with

Disabilities

Wyoming

Department of

Health Long

Term Care Unit

(LTC)

Tel (855)203-2936

8-5pm MST M-F

Fax (307)777-8399

N/A

 Nursing home program eligibility

questions

 Patient Contribution

 Waiver Programs

 Inpatient Hospital

 Hospice

 Home Health

Getting Help When You Need It__________________________________________________

Ch.2 Index 11 Revision 4/1/17

Agency Name &

Address

Telephone/Fax

Numbers

Web Address

Contact For:

Wyoming

Medicaid

N/A

http://wymedicaid.acs-

inc.com

 Provider manuals

 HIPAA electronic transaction data

exchange

 Fee schedules

 On-line Provider Enrollment

 Frequently asked questions (FAQs)

 Forms (e.g., Claim

Adjustment/Void Request Form)

 Contacts

 What’s new

 Remittance Advice Retrieval

 EDI enrollment form

 Trading Partner Agreement

 Secured Provider Web Portal

 Training Tutorials

HealthHelp

Tel (888) 545-1710

Option 2

https://wyhealth.net

 PA’s for Radiology, Cardiology

and Radiation Oncology

2.2 How to Call for Help

The fiscal agent maintains a well-trained call center that is dedicated to assisting

providers. These individuals are prepared to answer inquiries regarding client

eligibility, service limitations, third party coverage, electronic transaction questions

and provider payment issues.

2.3 How to Write for Help

In many cases, writing for help provides the provider with more detailed information

about the provider claims or clients. In addition, written responses may be kept as

permanent records.

Reasons to write vs. calling:

 Appeals – Include claim, all documentation previously submitted with the

claim, explanation for request, documentation supporting the request.

 Written documentation of answers – Include all documentation to support

the provider request.

 Rate change requests – Include request and any documentation supporting

the provider request.

 Requesting a service to be covered by Wyoming Medicaid – Include

request and any documentation supporting the provider request.

To expedite the handling of written inquiries, we recommend providers use a

Provider Inquiry Form (2.3.1, Provider Inquiry Form). Providers may copy the form

Getting Help When You Need It__________________________________________________

Ch.2 Index 12 Revision 4/1/17

in this manual. Provider Relations will respond to the provider inquiry within ten

business days of receipt.

2.3.1 Provider Inquiry Form

NOTE: Click image above to be taken to a printable version of this form.

2.4 How to Get a Provider Training Visit

Provider Relations Field Representatives are available to train or address questions

the provider’s office staff may have on Medicaid billing procedures or to resolve

claims payment issues.

Provider Relations Field Representatives are available to assist providers with help in

their location, by phone, or webinar with Wyoming Medicaid billing questions and

issues. Generally, to assist a provider with claims specific questions, it is best for the

Field Representative to communicate via phone or webinar as they will then have

access to the systems and tools needed to review claims and policy information.

Provider Training visits may be conducted when larger groups are interested in

training related to Wyoming Medicaid billing. When conducted with an individual

provider’s office, a Provider Training visit generally consists of a review of a

provider’s claims statistics, including top reasons for denials and denial rates, and a

review of important Medicaid training and resource information. Provider Training

Workshops may be held during the summer months to review this information in a

larger group format.

Getting Help When You Need It__________________________________________________

Ch.2 Index 13 Revision 4/1/17

Due to the rural and frontier nature, and weather in Wyoming, visits are generally

conducted during the warmer months only. For immediate assistance, a provider

should always contact Provider Relations (2.1, Quick Reference).

2.5 How to Get Help Online

The address for Medicaid’s public website is http://wymedicaid.acs-inc.com. This site

connects Wyoming’s provider community to a variety of information including:

 Answers to the providers frequently asked Medicaid questions.

 Claim, prior authorization, and other forms for download.

 Free download of latest WINASAP software and latest WINASAP updates.

 Free download of WINASAP Training Manuals and Tutorials.

 Medicaid publications, such as provider handbooks and bulletins.

 Payment Schedule.

 Primary resource for all information related to Medicaid.

 Wyoming Medicaid Secured Provider Web Portal.

 Wyoming Medicaid Secured Provider Web Portal tutorials.

The Medicaid public website also links providers to Medicaid’s Secured Provider

Web Portal, which delivers the following services:

 278 Electronic Prior Authorization Requests – Ability to submit and

retrieve prior authorization requests and responses electronically via the web.

 Data Exchange – Upload and download of electronic HIPAA transaction

files.

 Remittance Advice Reports – Retrieve recent Remittance Advices

o Wyoming Medicaid proprietary RA

 835

 User Administration – Add, edit, and delete users within the provider’s

organization who can access the Secured Provider Web Portal.

 837 Electronic Claim Entry – Interactively enter dental, institutional and

medical claims without buying expensive software.

 PASRR entry

 LT101 Look-Up

2.6 Training Seminars/Presentations

The fiscal agent and the Division of Healthcare Financing may sponsor periodic

training seminars at selected in-state and out-of-state locations. Providers will receive

advance notice of seminars by Medicaid bulletin email notifications, provider

Getting Help When You Need It__________________________________________________

Ch.2 Index 14 Revision 4/1/17

bulletins (hard copies) or Remittance Advice (RA) banners. Providers may also check

the Medicaid website for any recent seminar information.

Provider Responsibilities________________________________________________________

Ch. 3 Index 15 Revision 4/1/17

Chapter Three – Provider Responsibilities

3.1 Enrollment/Re-Enrollment .................................................................................. 16

3.1.1 Notifying Medicaid of Updated Provider Information ........................................ 18

3.1.2 Re-Certification ................................................................................................... 19

3.1.3 Discontinuing Participation in the Medicaid Program ........................................ 19

3.2 Accepting Medicaid Clients ................................................................................ 19

3.2.1 Compliance Requirements .................................................................................. 19

3.2.2 Provider-Patient Relationship .............................................................................. 19

3.2.2.1 Medicare/Medicaid Dual Eligible Clients ....................................................... 21

3.2.2.2 Accepting a Client as Medicaid After Billing the Client ................................. 22

3.2.2.3 Mutual Agreements Between the Provider & Client ....................................... 22

3.2.3 Missed Appointments .......................................................................................... 22

3.3 Medicare Covered Services ................................................................................. 23

3.4 Medical Necessity ............................................................................................... 23

3.5 Medicaid Payment is Payment in Full ................................................................. 24

3.6 Medicaid ID Card ................................................................................................ 25

3.7 Verification of Client Age ................................................................................... 25

3.8 Verification Options ............................................................................................ 25

3.8.1 Free Services ....................................................................................................... 25

3.8.2 Fee for Service ..................................................................................................... 26

3.9 Freedom of Choice .............................................................................................. 26

3.10 Out-of-State Service Limitations ......................................................................... 26

3.11 Record Keeping, Retention and Access .............................................................. 27

3.11.1 Requirements ....................................................................................................... 27

3.11.2 Retention of Records ........................................................................................... 28

3.11.3 Access to Records ............................................................................................... 28

3.11.4 Audits .................................................................................................................. 28

3.12 Tamper Resistant RX Pads .................................................................................. 30

Provider Responsibilities________________________________________________________

Ch. 3 Index 16 Revision 4/1/17

3.1 Enrollment/Re-Enrollment

Medicaid payment is made only to providers who are actively enrolled in the

Medicaid Program. Providers are required to complete an enrollment application,

undergo a screening process and sign a Provider Agreement at least every five (5)

years. In addition, certain provider types are required to pay an application fee,

submit proof of licensure and/or certification. These requirements apply to both in-

state and out-of-state providers.

All providers have been assigned one (1) of three (3) categorical risk levels under the

Affordable Care Act (ACA) and are required to be screened as follows:

Categorical Risk Level

Screening Requirements

LIMITED

Includes:

 Physician and nonphysican practitioners,

(includes nurse practitioners, CRNAs,

occupational therapists, speech/language

pathologist audiologists) and medical groups

or clinics

 Ambulatory surgical centers

 Competitive Acquisition Program/Part B

Vendors:

 End-stage renal disease facilities

 Federally qualified health centers (FQHC)

 Histocompatibility laboratories

 Hospitals, including critical access hospitals,

VA hospitals, and other federally-owned

hospital facilities

 Health programs operated by an Indian

Health program

 Mammography screening centers

 Mass immunization roster billers

 Organ procurement organizations

 Pharmacy newly enrolling or revalidating

via the CMS-855B application

 Radiation therapy centers

 Religious non-medical health care

institutions

 Rural health clinics

 Skilled nursing facilities

Verifies provider or supplier meets all applicable Federal regulations and

State requirements for the provider or supplier type prior to making an

enrollment determination

Conducts license verifications, including licensure verification across

State lines for physicians or non-physician practitioners and providers

and suppliers that obtain or maintain Medicare billing privileges as a

result of State licensure, including State licensure in States other than

where the provider or supplier is enrolling

Conducts database checks on a pre- and post-enrollment basis to ensure

that providers and suppliers continue to meet the enrollment criteria for

their provider/supplier type.

MODERATE

Includes:

 Ambulance service suppliers

 Community mental health centers (CMHC)

 Comprehensive outpatient rehabilitation

facilities (CORF)

 Hospice organizations

 Independent diagnostic testing facilities

 Physical therapists enrolling as individuals

or as group practices

 Portable x-ray suppliers

 Revalidating home health agencies

Revalidating DMEPOS suppliers

Performs the “limited” screening requirements listed above

Conducts an on-site visit

Provider Responsibilities________________________________________________________

Ch. 3 Index 17 Revision 4/1/17

Categorical Risk Level

Screening Requirements

HIGH

Includes:

 Prospective (newly enrolling) home

health agencies

 Prospective (newly enrolling)

DMEPOS suppliers

 Prosthetic/orthotic (newly enrolling)

suppliers

 Individual practitioners suspected of

identity theft, placed on previous

payment suspension, previously

excluded by the OIG, and/or

previously had billing privileges

denied or revoked within the last ten

(10) years

Performs the “limited” and “moderate” screening requirements listed

above.

Requires the submission of a set of fingerprints for a national

background check from all individuals who maintain a five (5) percent

or greater direct or indirect ownership interest in the provider or supplier.

Conducts a fingerprint-based criminal history record check of

the FBI’s Integrated Automated Fingerprint Identification

System on all individuals who maintain a five (5 percent or

greater direct or indirect ownership interest in the provider or

supplier

Categorical Risk Adjustment:

CMS adjusts the screening level from limited or moderate to high if any

of the following occur:

 Exclusion from Medicare by the OIG

 Had billing privileges revoked by a Medicare contractor within

the previous ten (10) years and is attempting to establish

additional Medicare billing privilege by—

o Enrolling as a new provider or supplier

o Billing privileges for a new practice location

 Has been terminated or is otherwise precluded from billing

Medicaid

 Has been excluded from any Federal health care program

Has been subject to a final adverse action as defined in §424.502 within

the previous ten (10) years

The ACA has imposed an application fee on the following institutional providers:

 In-state only

o Institutional Providers

o PRTFs

o Substance abuse centers (SAC)

o Wyoming Medicaid-only nursing facilities

o Community Mental Health Centers (CMHC)

o Wyoming Medicaid-only home health agencies (both newly enrolling

and re-enrolling)

Providers that are enrolled in Medicare, Medicaid in other states, and CHIP are only

required to pay one (1) enrollment fee. Verification of this payment must be included

with the enrollment application.

The application fee is required for:

 New enrollments

 Enrollments for new locations

 Re-enrollments

 Medicaid requested re-enrollments (as a result of inactive enrollment statuses)

Provider Responsibilities________________________________________________________

Ch. 3 Index 18 Revision 4/1/17

The application fee is non-refundable and is adjusted annually based on the Consumer

Price Index (CPI) for all urban consumers.

After a providers enrollment application has been approved, a welcome letter will be

sent.

If an application is not approved, a notice including the reasons for the decision will

be sent to the provider. No medical provider is declared ineligible to participate in the

Medicaid Program without prior notice.

To enroll as a Medicaid provider, all providers must complete the on-line enrollment

application available on the Medicaid website (2.1, Quick Reference).

3.1.1 Notifying Medicaid of Updated Provider Information

If any information listed on the original enrollment application subsequently changes,

providers must notify Medicaid in writing 30-days prior to the effective date of

the change. Changes that would require notifying Medicaid include, but are not

limited to, the following:

 Current licensing information

 Facility or name changes

 New ownership information

 New telephone or fax numbers

 Physical, correspondence or payment address change

 New email addresses

 Tax Identification Number

It is critical that providers maintain accurate contact information, including email

addresses, for the distribution of notifications to providers. Wyoming Medicaid policy

updates and changes are distributed by email, and occasionally by postal mail.

Providers are obligated to read, know and follow all policy changes. Individuals who

receive notifications on behalf of an enrolled provider are responsible for ensuring

they are distributed to the appropriate personnel in the organization, office, billing

office, etc.

Effective September 1, 2016, if any of the above contact information is found to be

inaccurate (mail is returned, emails bounce, phone calls are unable to be placed or

physical site verification fails, etc.) the provider will be placed on a claims hold.

Claims will be held for 30 days pending an update of the information. A letter will be

sent to the provider, unless both the physical and correspondence addresses have had

mail returned, notifying them of the hold and describing options to update contact

information. If the information is updated within the 30 days, the claim will be

released to complete normal processing; if a claim is held for this reason for more

than 30 days, it will then be denied and the provider will have to resubmit once the

incorrect information is updated. The letter will document the information currently

on file with Wyoming Medicaid and allow you to make updates/changes as needed.

Provider Responsibilities________________________________________________________

Ch. 3 Index 19 Revision 4/1/17

3.1.2 Re-Certification

Sixty (60) days prior to licensure/certification expiration Medicaid sends all providers

a letter requesting a copy of their license or other certifications. If these documents

are not submitted within 60-days of their expiration date, the provider will be

terminated as a Medicaid provider.

3.1.3 Discontinuing Participation in the Medicaid Program

The provider may discontinue participation in the Medicaid Program at any time.

Thirty (30) days written notice of voluntary termination is requested.

Notices should be addressed to Provider Relations, attention Enrollment Services

(2.1, Quick Reference).

3.2 Accepting Medicaid Clients

3.2.1 Compliance Requirements

All providers of care and suppliers of services participating in the Medicaid Program

must comply with the requirements of Title VI of the Civil Rights Act of 1964, which

requires that services be furnished to clients without regard to race, color, or national

origin.

Section 504 of the Rehabilitation Act provides that no individual with a disability

shall, solely by reason of the handicap:

 Be excluded from participation;

 Be denied the benefits; or

 Be subjected to discrimination under any program or activity receiving federal

assistance.

Each Medicaid provider, as a condition of participation, is responsible for making

provision for such individuals with a disability in their program activities.

As an agent of the Federal government in the distribution of funds, the Division of

Healthcare Financing is responsible for monitoring the compliance of individual

providers and, in the event a discrimination complaint is lodged, is required to

provide the Office of Civil Rights (OCR) with any evidence regarding compliance

with these requirements.

3.2.2 Provider-Patient Relationship

The relationship established between the client and the provider is both a medical and

a financial one. If a client presents himself/herself as a Medicaid client, the provider

must determine whether the provider is willing to accept the client as a Medicaid

patient before treatment is rendered.

Provider Responsibilities________________________________________________________

Ch. 3 Index 20 Revision 4/1/17

Providers must verify eligibility each month as programs and plans are re-

determined on a varying basis, and a client eligible one (1) month may not

necessarily be eligible the next month.

NOTE: Presumptive Eligibility may begin or end mid-month.

It is the provider’s responsibility to determine all sources of coverage for any client.

If the client is insured, by an entity other than Medicaid and Medicaid is unaware of

the insurance, the provider must submit a Third Party Resources Information Sheet

(7.7.1, Third Party Resources Information Sheet) to Medicaid. The provider may not

discriminate based on whether or not a client is insured.

Providers may not discriminate against Wyoming Medicaid clients. Providers must

treat Wyoming Medicaid clients the same as any other patient in their practice.

Policies must be posted or supplied in writing and enforced with all patients

regardless of payment source.

When and what may be billed to a Medicaid client.

Once this agreement has been reached, all Wyoming Medicaid covered services the

provider renders to an eligible client are billed to Medicaid.

Client is Covered

by a FULL

COVERAGE

Medicaid Program

and the provider

accepts the client as

a Medicaid client

Client is Covered by

a LIMITED

COVERAGE

Medicaid Program

and the provider

accepts the client as

a Medicaid client

FULL

COVERAGE or

LIMITED

COVERAGE

Medicaid Program

and the provider

does not accept the

client as a Medicaid

client

Client is not

covered by

Medicaid (not

a Medicaid

client)

Service is

covered by

Medicaid

Provider can bill the

client only for any

applicable copay

Provider can bill the

client if the category

of service is not

covered by the

client’s limited plan

Provider can bill the

client if written

notification has been

Provider may

bill client

Service is

covered by

Medicaid, but

client has

exceeded his/her

service

limitations (cap

limits)

Provider can bill the

client OR provider

Can request cap

limit waiver and bill

Medicaid

Provider can bill the

client OR provider

can request cap limit

waiver and bill

Medicaid

Provider can bill the

client if written

notification has been

given to the client

that they are not

being accepted as a

Medicaid client

Provider can

bill client

Provider Responsibilities________________________________________________________

Ch. 3 Index 21 Revision 4/1/17

Client is Covered

by a FULL

COVERAGE

Medicaid Program

and the provider

accepts the client as

a Medicaid client

Client is Covered by

a LIMITED

COVERAGE

Medicaid Program

and the provider

accepts the client as

a Medicaid client

FULL

COVERAGE or

LIMITED

COVERAGE

Medicaid Program

and the provider

does not accept the

client as a Medicaid

client

Client is not

covered by

Medicaid (not

a Medicaid

client)

Service is not

covered by

Medicaid

Provider can bill the

client only if a

specific financial

agreement has been

made in writing

Provider can bill the

client if the Category

of service is not

covered by the

client’s limited plan.

If the Category of

service is covered,

the provider can only

bill the client if a

specific financial

agreement has been

made in writing

Provider can bill the

client if written

notification has been

given to the client

that they are not

being accepted as a

Medicaid client

Provider can

bill client

Full Coverage Plan – Plan covers the full range of medical, dental, hospital, and

pharmacy services and may cover additional nursing home or waiver services.

Limited Coverage Plan – Plan with services limited to a specific category or type of

coverage.

Specific Financial Agreement – specific written agreement between a provider and a

client, outlining the specific services and financial charges for a specific date of

service, with the client agreeing to the financial responsibility for the charges.

3.2.2.1 Medicare/Medicaid Dual Eligible Clients

Dual eligible clients are those clients who have both Medicare and Medicaid. For

clients on the QMB plan, CMS guidelines indicate that coinsurance and deductible

amounts remaining after Medicare pays cannot be billed to the client under any

circumstances, regardless of whether you bill Medicaid or not.

For clients on other plans who are dual eligible, coinsurance and deductible amounts

remaining after Medicare payment cannot be billed to the client if the claim was

billed to Wyoming Medicaid, regardless of payment amount (including claims that

Medicaid pays at $0).

If the claim is not billed to Wyoming Medicaid, and the provider agrees in writing

prior to providing the service not to accept the client as a Medicaid client and advises

the client of his or her financial responsibility, and the client is not on a QMB plan,

then the client can be billed for the coinsurance and deductible under Medicare

guidelines.

Provider Responsibilities________________________________________________________

Ch. 3 Index 22 Revision 4/1/17

3.2.2.2 Accepting a Client as Medicaid After Billing the Client

If the provider collected money from the client for services rendered during the

eligibility period and decides later to accept the client as a Medicaid client, and

receive payment from Medicaid:

 Prior to submitting the claim to Medicaid, the provider must refund the entire

amount previously collected from the client to him or her for the services

rendered; and

 The 12-month timely filing deadline will not be waived (6.20, Timely Filing).

In cases of retroactive eligibility when a provider agrees to bill Medicaid for services

provided during the retroactive eligibility period:

 Prior to billing Medicaid, the provider must refund the entire amount

previously collected from the client to him or her for the services rendered;

and

 The twelve month timely filing deadline will be waived (6.20, Timely Filing).

NOTE: Medicaid will not pay for services rendered to the clients until eligibility

has been determined for the month services were rendered.

The provider may, at a subsequent date, decide not to further treat the client as a

Medicaid patient. If this occurs, the provider must advise the client of this fact in

writing before rendering treatment.

3.2.2.3 Mutual Agreements Between the Provider & Client

Medicaid covers only those services that are medically necessary and cost-efficient. It

is the providers’ responsibility to be knowledgeable regarding covered services,

limitations and exclusions of the Medicaid Program. Therefore, if the provider,

without mutual written agreement of the client, deliver services and are subsequently

denied Medicaid payment because the services were not covered or the services were

covered but not medically necessary and/or cost-efficient, the provider may not obtain

payment from the client.

If the provider and the client mutually agree in writing to services which are not

covered (or are covered but are not medically necessary and/or cost-efficient), and the

provider informs the client of his/her financial responsibility prior to rendering

service, then the provider may bill the client for the services rendered.

3.2.3 Missed Appointments

Provider Responsibilities________________________________________________________

Ch. 3 Index 23 Revision 4/1/17

Appointments missed by Medicaid clients cannot be billed to Medicaid. However, if

a provider’s policy is to bill all patients for missed appointments, then the provider

may bill Medicaid clients directly.

Any policy must be equally applied to all clients and a provider may not impose

separate charges on Medicaid clients, regardless of payment source. Policy must be

publically posted or provided in writing to all patients.

Medicaid only pays providers for services they render (i.e., services as identified in

1905 (a) of the Social Security Act). They must accept that payment as full

reimbursement for their services in accordance with 42 CFR 447.15. Missed

appointments are not a distinct, reimbursable Medicaid service. Rather, they are

considered part of a provider’s overall cost of doing business. The Medicaid

reimbursement rates set by the State are designed to cover the cost of doing business.

3.3 Medicare Covered Services

Claims for services rendered to clients eligible for both Medicare and Medicaid which

are furnished by an out-of-state provider must be filed with the Medicare

intermediary or carrier in the state in which the provider is located.

Questions concerning a client’s Medicare eligibility should be directed to the Social

Security Administration (2.1, Quick Reference).

3.4 Medical Necessity

The Medicaid Program is designed to assist eligible clients in obtaining medical care

within the guidelines specified by policy. Medicaid will pay only for medical services

that are medically necessary and are sponsored under program directives. Medically

necessary means the service is required to:

 Diagnose

 Treat

 Cure

 Prevent an illness which has been diagnosed or is reasonably suspected to:

o Relieve pain

o Improve and preserve health

o Be essential for life

Additionally, the service must be:

 Consistent with the diagnosis and treatment of the patient’s condition.

 In accordance with standards of good medical practice.

 Required to meet the medical needs of the patient and undertaken for reasons

other than the convenience of the patient or his/her physician.

Provider Responsibilities________________________________________________________

Ch. 3 Index 24 Revision 4/1/17

 Performed in the least costly setting required by the patient’s condition.

Documentation which substantiates that the client’s condition meets the coverage

criteria must be on file with the provider.

All claims are subject to both pre-payment and post-payment review for medical

necessity by Medicaid. Should a review determine that services do not meet all the

criteria listed above, payment will be denied or, if the claim has already been paid,

action will be taken to recoup the payment for those services.

3.5 Medicaid Payment is Payment in Full

As a condition of becoming a Medicaid provider (see provider agreement), the

provider must accept payment from Medicaid as payment in full for a covered

service.

The provider may never bill a Medicaid client:

 When the provider bills Medicaid for a covered service, and Medicaid denies

the providers claim due to billing errors such as wrong procedure and

diagnosis codes, lack of prior authorization, invalid consent forms, missing

attachments or an incorrectly filled out claim form.

 When Medicare or another third party payer has paid up to or exceeded what

Medicaid would have paid.

 For the difference in the providers charges and the amount Medicaid has paid

(balance billing).

The Provider may bill a Medicaid client:

 If the provider has not billed Medicaid, the service provided is not covered by

Medicaid, and prior to providing service, the provider informed the client in

writing that the service is non-covered and he/she is responsible for the

charges.

 If a provider does not accept a patient as a Medicaid client (because they

cannot produce a Medicaid ID card or because they did not inform the

provider they are eligible.

 If the client is not Medicaid eligible at the time the provider provides the

services or on a plan that does not cover those particular services. Refer to the

table above for guidance.

 If the client has exceeded the Medicaid limits on physical therapy,

occupational therapy, speech therapy, behavioral health services, chiropractic

services, prescriptions, and/or office/outpatient hospital visits. (6.9, Cap

Limits)

Provider Responsibilities________________________________________________________

Ch. 3 Index 25 Revision 4/1/17

NOTE: The provider may contact Provider Relations or the IVR to receive cap

limits for a client (2.1, Quick Reference).

 If the provider is an out-of-state provider and are not enrolled and have no

intention of enrolling.

3.6 Medicaid ID Card

It is each provider’s responsibility to verify the person receiving services is the same

person listed on the card. If necessary, providers should request additional materials

to confirm identification. It is illegal for anyone other than the person named on the

Medicaid ID Card to obtain or attempt to obtain services by using the card. Providers

who suspect misuse of a card should report the occurrence to the Program Integrity

Unit or complete the Report of Suspected Abuse of the Medicaid Healthcare System

Form (4.9, Referral of Suspected Fraud and Abuse).

3.7 Verification of Client Age

Because certain services have age restrictions, such as services covered only for

clients under the age of 21, and informed consent for sterilizations, providers should

verify a client’s age before a service is rendered.

Routine services may be covered through the month of the client’s 21st birthday.

3.8 Verification Options

One (1) Medicaid ID Card is issued to each client. Their eligibility information is

updated every month. The presentation of a card is not verification of eligibility. It is

each provider’s responsibility to ensure that their patient is eligible for the services

rendered. A client may state that he/she is covered by Medicaid, but not have any

proof of eligibility. This can occur if the client is newly eligible or if his/her card was

lost. Providers have several options when checking patient eligibility.

3.8.1 Free Services

The following is a list of free services offered by Medicaid for verifying client

eligibility:

 Contact Provider Relations. There is a limit of three (3) verifications per call

but no limit on the number of calls.

 Fax a list of identifying information to Provider Relations for verification.

Send a list of beneficiaries for verification and receive a response within ten

(10) business days.

Provider Responsibilities________________________________________________________

Ch. 3 Index 26 Revision 4/1/17

 Call the Interactive Voice Response (IVR) System. IVR is available 24-hours

a day, seven (7) days a week. The IVR System allows 30 minutes per phone

call. (2.1, Quick Reference).

 Use the Ask Wyoming Medicaid feature on the Secured Provider Web Portal

(2.1, Quick Reference).

3.8.2 Fee for Service

Several independent vendors offer web-based applications and/or swipe card readers

that electronically check the eligibility of Medicaid clients. These vendors typically

charge a monthly subscription and/or transaction fee. A complete list of approved

vendors is available on the Medicaid website.

3.9 Freedom of Choice

Any eligible non-restricted client may select any provider of health services in

Wyoming who participates in the Medicaid Program, unless Medicaid specifically

restricts his/her choice through provider lock-in or an approved Freedom of Choice

waiver. However, payments can be made only to health service providers who are

enrolled in the Medicaid Program.

3.10 Out-of-State Service Limitations

Medicaid covers services rendered to Medicaid clients when providers participating

in the Medicaid Program administer the services. If services are available in

Wyoming within a reasonable distance from the client’s home, the client must not

utilize an out-of-state provider.

Medicaid has designated the Wyoming Medical Service Area (WMSA) to be

Wyoming and selected border cities in adjacent states. WMSA cities include:

Colorado

Montana

South Dakota

Craig

Billings

Deadwood

Bozeman

Custer

Idaho

Rapid City

Montpelier

Nebraska

Spearfish

Pocatello

Kimball

Belle Fourche

Idaho Falls

Scottsbluff

Utah

Salt Lake City

Ogden

Provider Responsibilities________________________________________________________

Ch. 3 Index 27 Revision 4/1/17

NOTE: The cities of Greeley, Fort Collins, and Denver, Colorado are excluded

from the WMSA and are not considered border cities.

Medicaid compensates out-of-state providers within the WMSA when:

 The service is not available locally and the border city is closer for the

Wyoming resident than a major city in Wyoming; and

 The out-of-state provider in the selected border city is enrolled in Medicaid.

Medicaid compensates providers outside the WMSA only under the following

conditions:

 Emergency Care – When a client is traveling and an emergency arises due to

accident or illness.

 Other Care – When a client is referred by a Wyoming physician to a provider

outside the WMSA for services not available within the WMSA. The referral

must be documented in the provider’s records. Prior authorization is not

required unless the specific service is identified as requiring prior

authorization (6.14, Prior Authorization).

 Children in out-of-state placement.

If the provider is an out-of-state, non-enrolled provider and renders services to a

Medicaid client, the provider may choose to enroll in the Medicaid Program and

submit the claim according to Medicaid billing instructions, or bill the client.

Out-of-state providers furnishing services within the state on a routine or extended

basis must meet all of the certification requirements of the State of Wyoming. The

provider must enroll in Medicaid prior to furnishing services.

3.11 Record Keeping, Retention and Access

3.11.1 Requirements

The Provider Agreement requires that the medical and financial records fully disclose

the extent of services provided to Medicaid clients. The following elements include

but are not limited to:

 The record must be typed or legibly written.

 The record must identify the client on each page.

 The record must contain a preliminary working diagnosis and the elements of

a history and physical examination upon which the diagnosis is based.

 All services, as well as the treatment plan, must be entered in the record. Any

drugs prescribed as part of a treatment, including the quantities and the

Provider Responsibilities________________________________________________________

Ch. 3 Index 28 Revision 4/1/17

dosage, must be entered in the record. For any drugs administered, the NDC

on the product must be recorded, as well as the lot number and expiration

date.

 The record must indicate the observed medical condition of the client, the

progress at each visit, any change in diagnosis or treatment, and the client’s

response to treatment. Progress notes must be written for every service,

including, but not limited to: office, clinic, nursing home, or hospital visits

billed to Medicaid.

 Total treatment minutes of the client, including those minutes of active

treatment reported under the timed codes and those minutes represented by the

untimed codes, must be documented separately, to include beginning time and

ending time for services billed.

NOTE: Specific or additional documentation requirements may be listed in the

covered services sections or designated policy manuals.

3.11.2 Retention of Records

The provider must retain medical and financial records, including information

regarding dates of service, diagnoses, and services provided, and bills for services for

at least six (6) years from the end of the State fiscal year (July through June) in which

the services were rendered. If an audit is in progress, the records must be maintained

until the audit is resolved.

3.11.3 Access to Records

Under the Provider Agreement, the provider must allow access to all records

concerning services and payment to authorized personnel of-Medicaid, CMS

Comptroller General of the United States, State Auditor’s Office (SAO), the Office of

the Inspector General (OIG), the Wyoming Attorney General’s Office, the United

States Department of Health and Human Services, and/or their designees. Records

must be accessible to authorized personnel during normal business hours for the

purpose of reviewing, copying and reproducing documents. Access to the provider

records must be granted regardless of the providers continued participation in the

program.

In addition, the provider is required to furnish copies of claims and any other

documentation upon request from Medicaid and/or their designee.

3.11.4 Audits

Medicaid has the authority to conduct routine audits to monitor compliance with

program requirements.

Audits may include, but are not limited to:

Provider Responsibilities________________________________________________________

Ch. 3 Index 29 Revision 4/1/17

 Examination of records;

 Interviews of providers, their associates, and employees;

 Interviews of clients;

 Verification of the professional credentials of providers, their associates, and

their employees;

 Examination of any equipment, stock, materials, or other items used in or for

the treatment of clients;

 Examination of prescriptions written for clients;

 Determination of whether the healthcare provided was medically necessary;

 Random sampling of claims submitted by and payments made to providers;

and/or

 Audit of facility financial records for reimbursement.

 Actual records reviewed may be extrapolated and applied to all services billed

by the provider.

The provider must grant the State and its representative’s access during regular

business hours to examine medical and financial records related to healthcare billed to

the program. Medicaid notifies the provider before examining such records.

Medicaid reserves the right to make unscheduled visits i.e., when the client’s health

may be endangered, when criminal/fraud activities are suspected, etc.

Medicaid is authorized to examine all provider records in that:

 All eligible clients have granted Medicaid access to all personal medical

records developed while receiving Medicaid benefits.

 All providers who have at any time participated in the Medicaid Program, by

signing the Provider Agreement, have authorized the State and their

designated agents to access the provider’s financial and medical records.

 Provider’s refusal to grant the State and its representative’s access to examine

records or to provide copies of records when requested may result in:

 Immediate suspension of all Medicaid payments.

 All Medicaid payments made to the provider during the six (6)-year record

retention period for which records supporting such payments are not produced

shall be repaid to the Division of Healthcare Financing after written request

for such repayment is made.

 Suspension of all Medicaid payments furnished after the requested date of

service.

 Reimbursement will not be reinstated until adequate records are produced or

are being maintained.

 Prosecution under the Wyoming Statute.

Provider Responsibilities________________________________________________________

Ch. 3 Index 30 Revision 4/1/17

3.12 Tamper Resistant RX Pads

On May 25, 2007, Section 7002(b) of the U.S. Troop Readiness, Veterans’ Care,

Katrina Recovery, and Iraq Accountability Appropriations Act of 2007 was signed

into law.

The above law requires that ALL written, non-electronic prescriptions for Medicaid

outpatient drugs must be executed on tamper-resistant pads in order for them to be

reimbursable by the federal government. All prescriptions paid for by Medicaid must

meet the following requirements to help insure against tampering:

 Written Prescriptions: As of October 1, 2008 prescriptions, must contain all

three (3) of the following characteristics:

1. One (1) or more industry-recognized features designed to prevent

unauthorized copying of a completed or blank prescription form. In

order to meet this requirement all written prescriptions must contain:

 Some type of “void” or illegal pantograph that appears if the

prescription is copied.

 May also contain any of the features listed within category one,

recommendations provided by the National Council for

Prescription Drug Programs (NCPDP) or that meets the

standards set forth in this category.

2. One (1) or more industry-recognized features designed to prevent the

erasure or modification of information written on the prescription by

the prescriber. This requirement applies only to prescriptions written

for controlled substances. In order to meet this requirement all written

prescriptions must contain:

 Quantity check-off boxes PLUS numeric form of quantity

values OR alpha and numeric forms of quantity value.

 Refill Indicator (circle or check number of refills or “NR”)

PLUS numeric form of refill values OR alpha AND numeric

forms of refill values.

 May also contain any of the features listed within category two,

recommendations provided by the NCPDP, or that meets the

standards set forth in this category.

3. One (1) or more industry-recognized features designed to prevent the

use of counterfeit prescription forms. In order to meet this requirement

all written prescriptions must contain:

 Security features and descriptions listed on the FRONT of the

prescription blank.

 May also contain any of the features listed within category

three (3), recommendations provided by the NCPDP, or that

meets that standards set forth in this category.

Provider Responsibilities________________________________________________________

Ch. 3 Index 31 Revision 4/1/17

 Computer Printed Prescriptions: As of October 1, 2008 prescriptions, must

contain all three (3) of the following characteristics:

1. One (1) or more industry-recognized features designed to prevent

unauthorized copying of a completed or blank prescription form. In

order to meet this requirement all prescriber’s computer generated

prescriptions must contain:

 Same as Written Prescription for this category.

2. One (1) or more industry-recognized features designed to prevent the

erasure or modification of information printed on the prescription by

the prescriber. In order to meet this requirement all computer

generated prescriptions must contain:

 Same as Written Prescription for this category.

3. One (1) or more industry-recognized features designed to prevent the

use of counterfeit prescription forms. In order to meet this requirement

all prescriber’s computer generated prescriptions must contain:

 Security features and descriptions listed on the FRONT or

BACK of the prescription blank.

 May also contain any of the features listed within category

three (3), recommendations provided by the NCPDP, or that

meets the standards set forth in this category.

In addition to the guidance outlined above, the tamper-resistant requirement does not

apply when a prescription is communicated by the prescriber to the pharmacy

electronically, verbally, or by fax; when a managed care entity pays for the

prescription; or in most situations when drugs are provided in designated institutional

and clinical settings. The guidance also allows emergency fills with a non-compliant

written prescription as long as the prescriber provides a verbal, faxed, electronic, or

compliant written prescription within 72-hours.

Audits of pharmacies will be performed by the Wyoming Department of Health, to

ensure that the above requirement is being followed. If the provider has any questions

about these audits or this regulation, please contact the Pharmacy Program Manager

at (307)777-7531.

Utilization Review______________________________________________________________

Ch. 4 Index 32 Revision 4/1/17

Chapter Four – Utilization Review

4.1 Utilization Review ............................................................................................... 33

4.2 Complaint Referral .............................................................................................. 33

4.3 Release of Medical Records ................................................................................ 33

4.4 Client Lock-In ..................................................................................................... 34

4.5 Pharmacy Lock-In ............................................................................................... 34

4.6 Hospice Lock-In .................................................................................................. 35

4.7 Fraud and Abuse .................................................................................................. 35

4.8 Provider Responsibilities ..................................................................................... 36

4.9 Referral of Suspected Fraud and Abuse .............................................................. 36

4.9.1 Report of Suspected Abuse of the Medicaid Healthcare System ........................ 37

4.10 Sanctions ............................................................................................................. 37

4.11 Adverse Actions .................................................................................................. 38

Utilization Review______________________________________________________________

Ch. 4 Index 33 Revision 4/1/17

4.1 Utilization Review

The Division of Healthcare Financing (DHCF) has established a Program Integrity

Unit whose duties include, but are not limited to:

 Review of claims submitted for payment (pre and post payment reviews)

 Review of medical records and documents related to covered services

 Audit of medical records and client interviews

 Review of client Explanation of Medical Benefits (EOMB) responses

 Operation of the Surveillance/Utilization Review (SUR) process

 Provider screening and monitoring

 Program compliance and enforcement

4.2 Complaint Referral

The Program Integrity Unit reviews complaints regarding inappropriate use of

services from providers and clients. No action is taken without a complete

investigation. To file a complaint, please submit the details in writing and attach

supporting documentation to:

Program Integrity Unit

Division of Healthcare Financing

6101 Yellowstone Rd., Suite 210

Cheyenne, WY 82002

Or contact: (855) 846-2563

Or email: programintegrity@wyo.gov

4.3 Release of Medical Records

Every effort is made to ensure the confidentiality of records in accordance with

Federal Regulations and Wyoming Medicaid Rules. Medical records must be released

to the agency or its designee. The signed Provider Agreement allows the Division of

Healthcare Financing or its designated agent’s access to all medical and financial

records. In addition, each client agrees to the release of medical records to the

Division of Healthcare Financing when they accept Medicaid benefits.

The Division of Healthcare Financing will not reimburse for the copying of medical

records when the Division or its designated agents requests records.

Utilization Review______________________________________________________________

Ch. 4 Index 34 Revision 4/1/17

4.4 Client Lock-In

In designated circumstances, it may be necessary to restrict certain services or “lock-

in” a client to a certain physician, hospice, pharmacy or other provider. If a lock-in

restriction applies to a client, the lock-in information is provided on the Interactive

Voice Response System (2.1, Quick Reference).

A participating Medicaid provider who is not designated as the client’s primary

practitioner may provide and be reimbursed for services rendered to lock-in clients

only under the following circumstances:

 In a medical emergency where a delay in treatment may cause death or result

in lasting injury or harm to the client.

 As a physician covering for the designated primary physician or on referral

from the designated primary physician.

In cases where lock-in restrictions are indicated, it is the responsibility of each

provider to determine whether he/she may bill for services provided to a lock-in

client. Contact Provider Relations in circumstances where coverage of a lock-in client

is unclear. Refer to the Medicaid Pharmacy Provider Manual (2.1, Quick Reference).

4.5 Pharmacy Lock-In

The Medicaid Pharmacy Lock-In Program limits certain Medicaid clients to receiving

prescription services from multiple prescribers and utilizes multiple pharmacies

within a designated time period is a candidate for the Lock-In Program.

When a pharmacy is chosen to be a client’s designated Lock-In provider, notification

is sent to that pharmacy with all important client identifying information. If a Lock-In

client attempts to fill a prescription at a pharmacy other than their Lock-In pharmacy,

the claim will be denied with an electronic response of “NON-MATCHED

PHARMACY NUMBER-Pharmacy Lock-In”.

Pharmacies have the right to refuse Lock-In provider status for any client. The client

may be counseled to contact the Medicaid Pharmacy Case Manager at (307)777-8773

in order to obtain a new provider designation form to complete.

Expectations of a Medicaid designated Lock-In pharmacy:

 Medicaid pharmacy providers should be aware of the Pharmacy Lock-In

Program and the criteria for client lock-in status as stated above. The entire

pharmacy staff should be notified of current Lock-In clients.

 Review and monitor all drug interactions, allergies duplicate therapy, and

seeking of medications from multiple prescribers. Be aware that the client is

locked-in when “refill too soon” or “therapeutic duplication” edits occur. Cash

payment for controlled substances should serve as an alert and require further

review. Gather additional information which may include, but is not limited

to, asking the client for more information and/or contacting the prescriber.

Document findings and outcomes. The Wyoming Board of Pharmacy will be

Utilization Review______________________________________________________________

Ch. 4 Index 35 Revision 4/1/17

contacted when early refills and cash payment are allowed without appropriate

clinical care and documentation.

When doctor shopping for controlled substances is suspected, please contact the

Medicaid Pharmacy Case Manager at (307)777-8773. The Wyoming Online

Prescription Database (WORx) is online with 24/7 access for practitioners and

pharmacists. The WORx program is managed by the Wyoming Board of Pharmacy at

http://worxpdmp.com/ to view client profiles with all scheduled II through IV

prescriptions the client has received. The Wyoming Board of Pharmacy may be

reached at (307)634-9636 to answer questions about WORx.

EMERGENCY LOCK-IN PRESCRIPTIONS

If the dispensing pharmacist feels that in his/her professional judgment a prescription

should be filled and they are not the Lock-In provider, they may submit a hand-billed

claim to Goold Health Systems (GHS), an Emdeon company for review (2.1, Quick

Reference). Overrides may be approved for true emergencies (auto accidents, sudden

illness, etc.).

Any Wyoming Medicaid client suspected of controlled substance abuse, diversion, or

doctor shopping should be referred to the Medicaid Pharmacy Case Manager.

 Pharmacy Case Manager (307)777-8773 or

 Fax referrals to (307)777-6964.

 Referral forms may be found on the Pharmacy website (2.1, Quick

Reference).

4.6 Hospice Lock-In

Clients requesting coverage of hospice services under Wyoming Medicaid are locked-

in to the hospice for all care related to their terminal illness. All services and supplies

must be billed to the hospice provider, and the hospice provider will bill Wyoming

Medicaid for covered services. For more information regarding the hospice program,

refer to the Institutional Provider Manual on the Medicaid website (2.1, Quick

Reference).

4.7 Fraud and Abuse

The Medicaid Program operates under the anti-fraud provisions of Section 1909 of

the Social Security Act, as amended, and employs utilization management,

surveillance, and utilization review. The Program Integrity Unit’s function is to

perform pre- and post-payment review of services funded by Medicaid. Surveillance

is defined as the process of monitoring for service and controlling improper or illegal

utilization of the program. While the surveillance function addresses administrative

concerns, utilization review addresses medical concerns and may be defined as

monitoring and controlling the quality and appropriateness of medical services

Utilization Review______________________________________________________________

Ch. 4 Index 36 Revision 4/1/17

delivered to Medicaid clients. Medicaid may utilize the services of a Professional

Review Organization (PRO) to assist in these functions.

Since payment of claims is made from both State and Federal funds, submission of

false or fraudulent claims, statements, documents or concealment of material facts

may be prosecuted as a felony in either Federal or State court. The program has

processes in place for referral to the Medicaid Fraud Control Unit (MFCU) when

suspicion of fraud and abuse arise.

Medicaid has the responsibility, under Federal Regulations and Medicaid Rules, to

refer all cases of credible allegations of fraud and abuse to the MFCU. In accordance

with 42 CFR Part 455, and Medicaid Rules, the following definitions of fraud and

abuse are used:

4.8 Provider Responsibilities

The provider is responsible for reading and adhering to applicable State and Federal

regulations and the requirements set forth in this manual. The provider is also

responsible for ensuring that all employees are likewise informed of these regulations

and requirements. The provider certifies by his/her signature or the signature of

his/her authorized agent on each claim or invoice for payment that all information

provided to Medicaid is true, accurate, and complete. Although claims may be

prepared and submitted by an employee, billing agent or other authorized person,

providers are responsible for ensuring the completeness and accuracy of all claims

submitted to Medicaid.

4.9 Referral of Suspected Fraud and Abuse

If a provider becomes aware of possible fraudulent or program abusive

conduct/activity by another provider, or eligible client, the provider should notify the

Program Integrity Unit in writing. Return a completed Report of Suspected Abuse of

the Medicaid Healthcare System to or call or reference the below website:

Fraud

“An intentional deception or misrepresentation made by a person with the

knowledge that the deception could result in some unauthorized benefit to

himself or some other person. It includes any act that constitutes fraud

under applicable Federal or State law.”

Abuse

“Provider practices that are inconsistent with sound fiscal, business, or

medical practices, and result in an unnecessary cost to the Medicaid

program or in reimbursement for services that are not medically necessary

or that fail to meet professionally recognized standards for healthcare. It

also includes recipient practices that result in unnecessary cost to the

Medicaid Program.”

Utilization Review______________________________________________________________

Ch. 4 Index 37 Revision 4/1/17

Program Integrity Unit

Division of Healthcare Financing

6101 Yellowstone Rd., Suite 210

Cheyenne, WY 82002

Or contact: (855)846-2563

http://stopmedicaidfraud.wyo.gov/

4.9.1 Report of Suspected Abuse of the Medicaid Healthcare System

NOTE: Click image above to be taken to a printable version of this form.

4.10 Sanctions

The Division of Healthcare Financing (DHCF) may invoke administrative sanctions

against a Medicaid provider when a credible allegation of fraud abuse, waste, non-

compliance (i.e., Provider Agreement and/or Medicaid Rules) exists or who is under

sanction by another regulatory entity (i.e. Medicare, licensing boards, OIG, or other

Medicaid designated agents).

Providers who have had sanctions levied against them may be subject to prohibitions

or additional requirements as defined by Medicaid Rules (2.1, Quick Reference).

Utilization Review______________________________________________________________

Ch. 4 Index 38 Revision 4/1/17

4.11 Adverse Actions

Providers and clients have the right to request an administrative hearing regarding an

adverse action, after reconsideration, taken by the Division of Healthcare Financing.

This process is defined in Wyoming Medicaid Rule, Chapter 4, entitled “Medicaid

Administrative Hearings”.

Client Eligibility_______________________________________________________________

Ch. 5 Index 39 Revision 4/1/17

Chapter Five – Client Eligibility

5.1 What is Medicaid? ............................................................................................... 40

5.2 Who is Eligible? .................................................................................................. 40

5.2.1 Children ............................................................................................................... 40

5.2.2 Pregnant Women ................................................................................................. 41

5.2.3 Family MAGI Adult ............................................................................................ 41

5.2.4 Aged, Blind and Disabled ................................................................................... 41

5.2.4.1 Supplemental Security Income (SSI) and SSI Related .................................... 41

5.2.4.2 Institution ......................................................................................................... 41

5.2.4.3 Home and Community Based Waiver ............................................................. 42

5.2.5 Other .................................................................................................................... 42

5.2.5.1 Special Groups ................................................................................................. 42

5.2.5.2 Employed Individuals with Disabilities (EID) ................................................ 42

5.2.5.3 Medicare Savings Programs ............................................................................ 42

5.2.5.4 Non-Citizens with Medical Emergencies (ALEN) .......................................... 43

5.3 Maternal and Child Health (MCH) ..................................................................... 43

5.4 Eligibility Determination ..................................................................................... 43

5.4.1 Applying for Medicaid ........................................................................................ 43

5.4.2 Determination ...................................................................................................... 44

5.5 Client Identification Cards .................................................................................. 44

5.6 Other Types of Eligibility Identification ............................................................. 45

5.6.1 Medicaid Approval Notice .................................................................................. 45

Client Eligibility_______________________________________________________________

Ch. 5 Index 40 Revision 4/1/17

5.1 What is Medicaid?

Medicaid is a health coverage program jointly funded by the Federal government and

the State of Wyoming. The program is designed to help pay for medically necessary

healthcare services for children, pregnant women, family Modified Adjusted Gross

Income (MAGI) adults and the aged, blind and disabled.

5.2 Who is Eligible?

Eligibility is generally based on family income and sometimes resources and/or

healthcare needs. Federal statutes define more than 50 groups of individuals that may

qualify for Medicaid coverage. There are four (4) broad categories of Medicaid

eligibility in Wyoming:

 Children;

 Pregnant women;

 Family MAGI Adults; and

 Aged, Blind, and Disabled.

5.2.1 Children

 Newborns are automatically eligible if the mother is Medicaid eligible at the

time of the birth.

 Low Income Children are eligible if family income is at or below 133%

federal poverty level (FPL) or 154% FPL, dependent on age of the child.

 Presumptive Eligibility (PE) for Children allows temporary coverage for a

child who meets eligibility criteria for the full Children's Medicaid program

while the full Medicaid application is being processed.

o PE Coverage will end the date a determination is made on the full

Medicaid application or the last day of the next month after PE is

approved if a full Medicaid application is not submitted.

 Foster Care Children in Department of Family Services (DFS) custody are

eligible in different income levels including some who enter subsidized

adoption or who age out of foster care until they are age 26.

 Presumptive Eligibility (PE) for Former Foster Youth allows temporary

coverage for a person who meets eligibility criteria for the full Former Foster

Youth Medicaid program while the full Medicaid application is being

processed.

o PE Coverage will end the date a determination is made on the full

Medicaid application or the last day of the next month after PE is

approved if a full Medicaid application is not submitted.

Client Eligibility_______________________________________________________________

Ch. 5 Index 41 Revision 4/1/17

5.2.2 Pregnant Women

 Pregnant Women are eligible if family income is at or below 154% FPL.

Women with income less than or equal to the MAGI conversion of the 1996

Family Care Standard must cooperate with child support to be eligible.

 Presumptive Eligibility (PE) for Pregnant Women allows temporary outpatient

coverage for a pregnant woman who meets eligibility criteria for the full

Pregnant Woman Medicaid program while the full Medicaid application is

being processed.

o PE Coverage will end the date a determination is made on the full

Medicaid application or the last day of the next month after PE is

approved if a full Medicaid application is not submitted.

5.2.3 Family MAGI Adult

 Family MAGI Adults (caretaker relatives with a dependent child) are eligible

if family income is at or below the MAGI conversion of the 1996 Family Care

Standard.

 Presumptive Eligibility (PE) for Caretaker Relatives allows temporary

coverage for the parent or caretaker relative of a Medicaid eligible child who

meets eligibility criteria for the full Family MAGI Medicaid program while

the full Medicaid application is being processed.

o PE Coverage will end the date a determination is made on the full

Medicaid application or the last day of the next month after PE is

approved if a full Medicaid application is not submitted.

5.2.4 Aged, Blind and Disabled

5.2.4.1 Supplemental Security Income (SSI) and SSI Related

 SSI – A person receiving SSI automatically qualifies for Medicaid

 SSI Related – A person no longer receiving SSI payment may be eligible

using SSI criteria.

5.2.4.2 Institution

All categories are income eligible up to 300% SSI Standard.

 Nursing Home

 Hospital

 Hospice

 ICF ID – Wyoming Life Resource Center

 INPAT-PSYCH – WY State Hospital – clients are 65 years and older.

Client Eligibility_______________________________________________________________

Ch. 5 Index 42 Revision 4/1/17

5.2.4.3 Home and Community Based Waiver

All waiver groups are income eligible when income is less than or equal to 300% SSI

Standard.

 Acquired Brain Injury

 Assisted Living Facilities

 Children’s Mental Health

 Comprehensive

 Long Term Care

 Supports

5.2.5 Other

5.2.5.1 Special Groups

 Breast and Cervical Cancer (BCC) Treatment Program – Uninsured

women diagnosed with breast or cervical cancer are income eligible at or

below 250% FPL

 Presumptive Eligibility (PE) for BCC allows temporary coverage for a woman

who meets eligibility criteria for the full BCC Medicaid program while the

full Medicaid application is being processed.

o PE Coverage will end the date a determination is made on the full

Medicaid application or the last day of the next month after PE is

approved if a full Medicaid application is not submitted.

 Tuberculosis (TB) Program – Individuals diagnosed with tuberculosis are

eligible based on the TB Standard.

 Program for All Inclusive Care for the Elderly (PACE) – Individuals over

the age of 55 assessed to be in need of nursing home level of care receive all

services coordinated through the PACE provider. This program is currently

available in Laramie County only.

5.2.5.2 Employed Individuals with Disabilities (EID)

Employed Individuals with Disabilities are income eligible when income is less than

or equal to 300% SSI using unearned income and must pay a premium calculated

using total gross income.

5.2.5.3 Medicare Savings Programs

 Qualified Medicare Beneficiaries (QMB) are income eligible at or below

100% FPL. Benefits include payment of Medicare premiums, deductibles, and

cost sharing.

 Specified Low Income Beneficiaries (SLMB) are income eligible at or below

135% FPL. Benefits include payment of Medicare premiums only.

Client Eligibility_______________________________________________________________

Ch. 5 Index 43 Revision 4/1/17

5.2.5.4 Non-Citizens with Medical Emergencies (ALEN)

A non-citizen who meets all eligibility factors under a Medicaid group except for

citizenship and social security number is eligible for emergency services. This does

not include dental services.

5.3 Maternal and Child Health (MCH)

Maternal and Child Health (MCH) provides services for high-risk pregnant women,

high-risk newborns and children with special healthcare needs through the Children’s

Special Health (CSH) program. The purpose is to identify eligible clients, assure

diagnostic and treatment services are available, provide payment for authorized

specialty care for those eligible, and provide care coordination services. CSH does not

cover acute or emergency care.

 A client may be eligible only for a MCH program or may be dually eligible

for a MCH program or other Medicaid programs. Care coordination for both

MCH only and dually eligible clients is provided through the Public Health

Nurse (PHN).

 MCH has a dollar cap and limits on some services for those clients who are

eligible for MCH only.

 Contact MCH for the following information:

o The nearest Public Health Nurse (PHN)

o Questions related to eligibility determination

o Questions related to the type of services authorized by MCH.

Maternal & Child Health

6101 N. Yellowstone Rd., Ste. 420

Cheyenne, WY 82002

(800)438-5795 or Fax: (307)777-7215

Providers must be enrolled with Medicaid and MCH to receive payment for MCH

services. Claims for both programs are submitted to and processed by the fiscal agent

for Wyoming Medicaid (2.1, Quick Reference). Providers are asked to submit the

medical record to CSH in a timely manner assure coordination of referrals and

services.

5.4 Eligibility Determination

5.4.1 Applying for Medicaid

 Persons applying for Children, Pregnant Women and/or Family MAGI Adult

programs may complete the Application for Wyoming’s Healthcare Coverage,

which is also used for the Kid Care CHIP program. The application may be

Client Eligibility_______________________________________________________________

Ch. 5 Index 44 Revision 4/1/17

mailed to the Wyoming Department of Health (WDH). Applicants may also

apply online at https://www.wesystem.wyo.gov/.

 Presumptive Eligibility (PE) applicants may also apply through a qualified

provider or qualified hospital for the PE programs.

5.4.2 Determination

Eligibility determination is conducted by the Wyoming Department of Health

Customer Service Center (CSC) or the Long Term Care (LTC) Unit centrally located

in Cheyenne, WY (2.1, Quick Reference).

Persons who want to apply for other programs offered through the Department of

Family Services (DFS), such as Supplemental Nutrition Assistance Program (SNAP)

or Child Care need to apply in person at their local DFS office. Persons applying for

Supplemental Security Income (SSI) need to contact the Social Security

Administration (SSA) (2.1, Quick Reference).

Medicaid assumes no financial responsibility for services rendered prior to the

effective date of client eligibility as determined by the WDH or the SSA. However,

the effective date of eligibility as determined by the WDH may be retroactive up to

90-days prior to the month in which the application is filed, as long as the client

meets eligibility criteria during each month of the retroactive period. If the SSA

deems the client eligible, the period of original entitlement could precede the

application date beyond the 90-day retroactive eligibility period and/or the 12-month

timely filing deadline for Medicaid claims (6.20, Timely Filing). This situation could

arise for the following reasons:

 Administrative Law Judge decisions or reversals.

 Delays encountered in processing applications or receiving necessary client

information concerning income or resources.

5.5 Client Identification Cards

A Medicaid ID Card is mailed to clients upon enrollment in the Medicaid Program or

other health programs such as the AIDS Drug Assistance Program (ADAP),

Children’s Special Health (CSH), and Prescription Drug Assistance Program (PDAP).

Not all programs receive a Medicaid ID Card, to confirm if a plan generates a card or

not refer to the “card” indicator on the Medicaid and State Benefit Plan Guide.

Sample Medicaid ID card:

Client Eligibility_______________________________________________________________

Ch. 5 Index 45 Revision 4/1/17

5.6 Other Types of Eligibility Identification

5.6.1 Medicaid Approval Notice

In some cases, a provider may be presented with a copy of a Medicaid Approval

Notice in lieu of the client’s Medicaid ID Card. Providers should always verify

eligibility before rendering services to a client who presents a Medicaid Approval

Notice.

NOTE: Refer to “Verification Options” (3.8, Verification Options) on ways to

verify a client’s eligibility.

Common Billing Information ____________________________________________________

Ch. 6 Index 46 Revision 4/1/17

Chapter Six – Common Billing Information

6.1 Electronic Billing ................................................................................................ 49

6.2 Basic Paper Claim Information ........................................................................... 49

6.3 Authorized Signatures ......................................................................................... 50

6.4 Completing the CMS-1500 Claim Form ............................................................. 51

6.4.1 Instructions for Completing the CMS-1500 Claim Form ................................... 51

6.4.2 Place of Service ................................................................................................... 56

6.5 Medicare Crossovers ........................................................................................... 61

6.5.1 General Information ............................................................................................ 61

6.5.2 Billing Information .............................................................................................. 62

6.6 Examples of Billing ............................................................................................. 63

6.6.1 Client has Medicaid Coverage Only or Medicaid and Medicare Coverage ........ 63

6.6.2 Client has Medicaid and Third Party Liability (TPL) or Client has Medicaid,

Medicare and TPL ............................................................................................... 64

6.7 National Drug Code (NDC) Billing Requirement ............................................... 65

6.7.1 Converting 10-Digit NDC’s to 11-Digits ............................................................ 65

6.7.2 Documenting and Billing the Appropriate NDC ................................................. 66

6.7.3 Procedure Code/NDC Combinations .................................................................. 67

6.7.4 Billing Requirements ........................................................................................... 67

6.7.5 Submitting One NDC per Procedure Code ......................................................... 67

6.7.6 Submitting Multiple NDCs per Procedure Code ................................................. 68

6.7.7 Medicare Crossover Claims ................................................................................ 68

6.7.8 CMS-1500 02-12 Billing Instructions ................................................................. 68

6.8 Cap Limits ........................................................................................................... 69

6.8.1 Cap Limit Waiver ................................................................................................ 70

6.8.2 Cap Limit Waiver Request Form ........................................................................ 71

6.8.3 Cap Limit Waiver Request Form Instructions .................................................... 72

6.8.4 Cap Limit Additional Information for Clients Under the Age of 21 ................... 73

6.8.5 Cap Limit Additional Information Instructions ................................................... 74

6.9 Reimbursement Methodologies ........................................................................... 75

Common Billing Information ____________________________________________________

Ch. 6 Index 47 Revision 4/1/17

6.10 Usual and Customary Charges ............................................................................ 75

6.10.1 Invoice Charges ................................................................................................... 75

6.11 Co-Payment Schedule ......................................................................................... 76

6.12 How to Bill for Newborns ................................................................................... 76

6.13 Prior Authorization .............................................................................................. 76

6.13.1 Requesting Prior Authorization from Medical Policy ......................................... 77

6.13.1.1 Medicaid Prior Authorization Form ................................................................ 79

6.13.1.2 Instructions for Completing the Medicaid Prior Authorization Form ............. 79

6.13.2 Requesting an Emergency Prior Authorization ................................................... 81

6.13.2.1 Prior Authorization Approval .......................................................................... 81

6.13.2.2 Sample PA Approval Letter ............................................................................ 82

6.13.2.3 Prior Authorization Denial .............................................................................. 83

6.13.2.4 Sample Prior Authorization Denial Letter ....................................................... 83

6.13.2.5 Prior Authorization Pending ............................................................................ 84

6.13.2.6 Sample Prior Authorization Pending ............................................................... 84

6.14 Order vs Delivery Date ........................................................................................ 85

6.14.1 Order vs Delivery Date Exception Form ............................................................. 86

6.15 Submitting Attachments for Electronic Claims ................................................... 86

6.15.1 Attachment Cover Sheet ...................................................................................... 88

6.16 Sterilization, Hysterectomy and Abortion Consent Forms ................................. 88

6.16.1 Sterilization Consent Form and Guidelines ......................................................... 88

6.16.1.1 Sterilization Consent Form .............................................................................. 90

6.16.1.2 Instructions for Completing the Sterilization Consent Form........................... 90

6.16.2 Hysterectomy Acknowledgment of Consent ....................................................... 90

6.16.2.1 Instructions for Completing the Hysterectomy Acknowledgment of Consent

Form ................................................................................................................ 92

6.16.2.2 Hysterectomy Acknowledgment Consent Form.............................................. 93

6.16.3 Abortion Certification Guidelines ....................................................................... 93

6.16.3.1 Instructions for Completing the Abortion Certification Form ......................... 93

6.16.3.2 Abortion Certification Form ............................................................................ 94

6.17 Remittance Advice .............................................................................................. 94

6.17.1 Sample Professional Remittance Advice ............................................................ 96

Common Billing Information ____________________________________________________

Ch. 6 Index 48 Revision 4/1/17

6.17.2 How to Read the Remittance Advice .................................................................. 97

6.17.3 Remittance Advice Replacement Request Policy ............................................... 98

6.17.3.1 Remittance Advice (RA) Replacement Request Form .................................... 99

6.17.4 Obtain an RA from the Web ................................................................................ 99

6.17.5 When a Client Has Other Insurance .................................................................... 99

6.18 Resubmitting Versus Adjusting Claims ............................................................ 100

6.18.1 How Long do Providers Have to Resubmit or Adjust a Claim? ....................... 100

6.18.2 Resubmitting a Claim ........................................................................................ 101

6.18.2.1 When to Resubmit to Medicaid ..................................................................... 101

6.18.3 Adjustment/Void Request Form Electronically Adjusting Paid Claims via

Hardcopy/Paper ................................................................................................. 101

6.18.3.1 Adjustment/Void Request Form .................................................................... 102

6.18.3.2 How to Request an Adjustment/Void ............................................................ 102

6.18.3.3 How to Complete the Adjustment/Void Request Form ................................. 103

6.18.3.4 When to Request an Adjustment ................................................................... 103

6.18.3.5 When to Request a Void ................................................................................ 104

6.19 Credit Balances .................................................................................................. 104

6.20 Timely Filing ..................................................................................................... 105

6.20.1 Exceptions to the Twelve-Month Limit ............................................................ 105

6.20.2 Appeal of Timely Filing .................................................................................... 106

6.20.2.1 How to Appeal ............................................................................................... 106

6.21 Important Information Regarding Retroactive Eligibility Decisions ................ 106

6.22 Client Fails to Notify a Provider of Eligibility .................................................. 107

6.23 Billing Tips to Avoid Timely Filing Denials .................................................... 107

6.24 Telehealth .......................................................................................................... 108

6.24.1 Covered Services ............................................................................................... 108

6.24.2 Non-Covered Services ....................................................................................... 110

6.24.3 Billing Requirements ......................................................................................... 110

Common Billing Information ____________________________________________________

Ch. 6 Index 49 Revision 4/1/17

6.1 Electronic Billing

As of July 1, 2015 Wyoming Medicaid requires all providers to submit electronically.

There are two (2) exceptions to this requirement:

 Providers who do not submit at least 25 claims in a calendar year.

 Providers who do not bill diagnosis codes on their claims.

If a provider is unable to submit electronically, the provider must submit a request for

an exemption in writing and must include:

 Provider name, NPI, contact name and phone number.

 The calendar year for which the exemption is being requested.

 Detailed explanation of the reason for the exemption request.

Mail to:

Wyoming Medicaid

Attn: Provider Relations

PO Box 667

Cheyenne, WY 82003-0667

A new exemption request must be submitted for each calendar year. Wyoming

Medicaid has free software or applications available for providers to bill

electronically (Chapter 8, Electronic Data Interchange (EDI)).

6.2 Basic Paper Claim Information

The fiscal agent processes paper CMS-1500 and UB04 claims using Optical

Character Recognition (OCR). OCR is the process of using a scanner to read the

information on a claim and convert it into electronic format instead of being manually

entered. This process improves accuracy and increases the speed at which claims are

entered into the claims processing system. The quality of the claim will affect the

accuracy in which the claim is processed through OCR. The following is a list of tips

to aid providers in avoiding paper claims processing problems with OCR:

 Use an original, standard, red-dropout form (CMS-1500 (02-12) and UB04).

 Use typewritten print; for best results use a laser printer.

 Use a clean, non-proportional font.

 Use black ink.

 Print claim data within the defined boxes on the claim form.

 Print only the information asked for on the claim form.

 Use all capital letters.

Common Billing Information ____________________________________________________

Ch. 6 Index 50 Revision 4/1/17

 Use correction tape for corrections.

To avoid delays in the processing of claims it is recommended that providers avoid

the following:

 Using copies of claim forms.

 Faxing claims.

 Using fonts smaller than 8 point.

 Resizing the form.

 Handwritten information on the claim form.

 Entering “none”, “NA”, or “Same” if there is no information (leave the box

blank).

 Mixing fonts on the same claim form.

 Using italics or script fonts.

 Printing slashed zeros.

 Using highlighters to highlight field information.

 Using stamps, labels, or stickers.

 Marking out information on the form with a black marker.

Claims that do not follow Medicaid provider billing policies and procedures may be

returned unprocessed with a letter or may be processed incorrectly. When a claim is

returned the provider may correct the claim and return it to Medicaid for processing.

NOTE: The fiscal agent and the Division of Healthcare Financing (DHCF) are

prohibited by federal law from altering a claim.

Billing errors detected after a claim is submitted cannot be corrected until after

Medicaid has made payment or notified the provider of the denial. Providers should

not resubmit or attempt to adjust a claim until it is reported on their Remittance

Advice (6.18, Resubmitting Versus Adjusting Claims).

NOTE: Claims are to be submitted only after service(s) have been rendered, not

before. For deliverable items (i.e. dentures, DME, glasses, hearing aids,

etc.) the date of service must be the date of delivery, not the order date.

6.3 Authorized Signatures

All paper claims must be signed by the provider or the provider’s authorized

representative. Acceptable signatures may be either handwritten, a stamped facsimile,

typed, computer generated, or initialed. The signature certifies all information on the

Common Billing Information ____________________________________________________

Ch. 6 Index 51 Revision 4/1/17

claim is true, accurate, complete, and contains no false or erroneous information.

Remarks such as signature on file or facility names will not be accepted.

6.4 Completing the CMS-1500 Claim Form

6.4.1 Instructions for Completing the CMS-1500 Claim Form

Claim

Item

Title

Required

Conditionally

Required

Action/Description

Insurance Type

Place an "X" in the "Medicaid" box.

Insured’s ID

Number

Enter the client’s ten (10) digit Medicaid ID

number that appears on the Medicaid

Identification card.

Patient’s Name

Enter the client’s last name, first name, and

middle initial.

Patient’s Date of

Birth/Sex

Information that will identify the patient and

distinguishes persons with similar names.

Common Billing Information ____________________________________________________

Ch. 6 Index 52 Revision 4/1/17

Claim

Item

Title

Required

Conditionally

Required

Action/Description

Insured’s Name

Enter the insured’s full last name, first

name, and middle initial. Insured’s name

identifies who holds the policy if different

than Patient information.

Patient’s Address

Refers to patient’s permanent residence.

Patient’s

Relationship to

Insured

If the client is covered by other insurance,

mark the appropriate box to show

relationship.

Insured’s Address

Enter the address of the insured.

Patient Status

Indicates patient’s marital and employment

status.

Instruct

ions for

9a-d

Other Insurance

Information

If item number 11d is marked complete

fields 9 and 9a-d.

Other Insured’s

Name

When additional group health coverage

exists, enter other insured’s full last name,

first name and middle initial of the enrollee

if different from item number 2.

Other Insured’s

Policy or Group

Name

Enter the policy or group number of the

other insured.

Reserved for

NUCC Use

Reserved for

NUCC Use

Insurance Plan or

Program Name

Enter the other insured’s insurance plan or

program name.

10a-c

Is Patient’s

Condition Related

to?

When appropriate, enter an X in the correct

box to indicate whether one or more the

services described in Item Number 24 are

for a condition or injury the occurred on the

job or as a result of an auto accident.

10d

Reserved for Local

Use

Insured’s Policy,

group or FECA

Number

Enter the insured’s policy or group number

as it appears on the ID card. Only complete

if Item Number 4 is completed.

11a

Insured’s Date of

Birth, Sex

Enter the 8- digit date of birth

(MM/DD/CCYY) and an X to indicate the

sex of the insured.

11b

Insured’s

Employer’s Name

or School Name

Enter the Name of the insured’s employer or

school.

Common Billing Information ____________________________________________________

Ch. 6 Index 53 Revision 4/1/17

Claim

Item

Title

Required

Conditionally

Required

Action/Description

11c

Insurance Plan

Name or Program

Name

Enter the insurance plan or program name

of the insured.

11d

Is there another

Health Benefit

Plan?

When appropriate, enter an X in the correct

box. If marked “YES”, complete 9 and 9a-d.

Patient’s or

Authorized

Person’s Signature

Indicates there is an authorization on file for

the release of any medical or other

information necessary to process the claim.

Payment

Authorization

Signature

Indicates that there is a signature on file

authorizing payment of medical benefits.

Date of current

illness, injury or

pregnancy

Enter the date of illness, injury or

pregnancy.

If Patient has had

Same or Similar

Illness

A patient having had same or similar illness

would indicate that the patient had a

previously related condition.

Date Patient

Unable to Work in

Current

Occupation

Time span the patient is or was unable to

work.

Name of Referring

Physician

Enter the name and credentials of the

professional who referred, ordered or

supervised the service on the claim.

17a

17a Other ID #

Other ID number of the referring, ordering,

or supervising provider is reported in 17a in

the shaded area. The qualifier indicating

what the number represents is reported in

the qualifier field to the immediate right.

17b

NPI #

Enter the NPI number of the referring,

ordering, or supervising provider in Item

Number 17b.

Hospitalization

Dates Related to

Current Service

The hospitalization dates related to current

services would refer to an inpatient stay and

indicates admission and discharge dates.

Reserved for Local

Use

Outside lab? $

Charges

Indicates that services have been rendered

by an independent provider as indicated in

Item Number 32 and related Costs.

Common Billing Information ____________________________________________________

Ch. 6 Index 54 Revision 4/1/17

Claim

Item

Title

Required

Conditionally

Required

Action/Description

ICD Indicator

Diagnosis or

Nature of Illness or

Injury

Enter the ICD-9 or ICD-10 indicator Enter

the patient’s diagnosis/condition. List up to

twelve ICD-PCM codes. Use the highest

level of specificity. Do not provide a

description in this field.

Medicaid

Resubmission

Code

The code and original reference number

assigned by the destination payer or receiver

to indicate a previously submitted claim.

Prior Authorization

Enter the ten (10) digit Prior Authorization

number from the approval letter, if

applicable. Claims for these services are

subject to service limits and the 12 month

filing limit.

Claim Line Detail

Supplemental information is to be placed in

the shaded sections of 24A through 24G as

required by individual payers. Medicaid

requires information such as NDC and

taxonomy in the shaded areas as defined in

each Item Number

24A

Dates of Service

Enter date(s) of service, from and to. If one

(1) date of service only enter that date under

“from”. Leave “to” blank or reenter “from”

date. Enter as MM/DD/YY. NDC qualifier

and NDC code will be placed in the shaded

area. For detailed information on billing

with the corresponding NDC codes, refer to

the NDC entry information following this

instruction table.

24B

Place of Service

Enter the two (2) digit Place of Service

(POS) code for each procedure performed.

24C

EMG

This field is used to identify if the service

was an emergency. Provider must maintain

documentation supporting an emergency

indicator. Enter Y for “YES” or leave blank

or enter N for “NO” in the bottom, un-

shaded area of the field. This field is

situational, but required when the service is

deemed an emergency

24D

Procedures,

Services, or

Supplies

Enter the CPT or HCPCS codes and

modifiers from the appropriate code set in

effect on the date of service.

Common Billing Information ____________________________________________________

Ch. 6 Index 55 Revision 4/1/17

Claim

Item

Title

Required

Conditionally

Required

Action/Description

24E

Diagnosis Pointer

Enter the diagnosis code reference letter

(pointer) as shown in Item Number 21 to

relate the date of service and the procedures

performed to the primary diagnosis. Do Not

enter any diagnosis codes in this box.

24F

$ Charges

Enter the charge for each listed service.

24G

Days or Units

Enter the units of services rendered for each

detail line. A unit of service is the number

of times a procedure is performed. If only

one (1) service is performed, the numeral 1

must be entered.

24H

EPSDT/Family

Plan

Identifies certain services that may be

covered under some state plans.

24I

ID Qualifier

If the provider does not have an NPI

number, enter the appropriate qualifier and

identifying number in the shaded area

(Chapter 9, Wyoming Specific HIPAA

5010).

24J

Rendering

Provider ID #

The individual rendering the service is

reported in 24J. Enter the taxonomy code in

the shaded area of the field. Enter the NPI

number in the un-shaded area of the field.

Report the Identification Number in Items

24I and 24J only when different from the

data in Items 33a and 33b.

Federal Tax ID

Number

Refers to the unique identifier assigned by a

federal or state agency.

Patient’s Account

Number

The patient’s account number refers to the

identifier assigned by the provider

(optional).

Assignment?

Enter X in the correct box. Indicated that the

provider agrees to accept assignment under

the terms of the Medicare program.

Total Charge

Add all charges in Column 24F and enter

the total amount in this field.

Amount Paid

Enter total amount the patient or other

payers paid on the covered services only.

This field is reserved for third party

coverage only, do not enter Medicare paid

amounts

Balance Due

Enter the total amount due.

Common Billing Information ____________________________________________________

Ch. 6 Index 56 Revision 4/1/17

Claim

Item

Title

Required

Conditionally

Required

Action/Description

Signature of

Physician or

Supplier Including

Degrees or

Credentials

Enter the legal signature of the practitioner

or supplier, signature of the practitioner or

supplier representative. Enter date the form

was signed.

32, 32a

and 32b

Split

Field

32 -Service

Facility Location

Information

32a NPI Number

32b Other ID#

Enter the name, address, city, state and zip

code of the location where the services were

rendered. Enter the NPI number of the

service facility location in 32a; enter the two

(2) digit qualifier identifying the non-NPI

number followed by the ID number.

33, 33a

and 33b

Split

Field

33 -Billing

Provider Info &

Ph#

33a NPI number

33b taxonomy

Enter the provider’s or supplier’s billing

name, address, zip code and phone number.

Enter the NPI number of the billing provider

in 33a. Enter the two (2) digit qualifier

identifying the non-NPI number followed

by the ID number. Enter the provider’s

taxonomy number in 33b.

6.4.2 Place of Service

Place

Service

Place of Service Name

Place of Service Description

Pharmacy

A facility or location where drugs and other medically

related items and services are sold, dispensed, or

otherwise provided directly to patients.

Unassigned

N/A

School

A facility whose primary purpose is education.

Homeless Shelter

A facility or location whose primary purpose is to

provide temporary housing to homeless individuals (e.g.,

emergency shelters, individual or family shelters).

Indian Health

Service Free-

standing Facility

A facility or location, owned and operated by the Indian

Health Service, which provides diagnostic, therapeutic

(surgical and non-surgical), and rehabilitation services to

American Indians and Alaska Natives who do not require

hospitalization.

Indian Health

Service Provider-

based Facility

A facility or location, owned and operated by the Indian

Health Service, which provides diagnostic, therapeutic

(surgical and non-surgical), and rehabilitation services

rendered by, or under the supervision of, physicians to

American Indians and Alaska Natives admitted as

inpatients or outpatients.

Common Billing Information ____________________________________________________

Ch. 6 Index 57 Revision 4/1/17

Place

Service

Place of Service Name

Place of Service Description

Tribal 638 Free-

standing Facility

A facility or location owned and operated a federally

recognized American Indian or Alaska Native tribe or

tribal organization under a 638 agreement, which

provides diagnostic, therapeutic (surgical and non-

surgical), and rehabilitation services to tribal members

who do not require hospitalization.

Tribal 638 Provider-

based Facility

A facility or location owned and operated a federally

recognized American Indian or Alaska Native tribe or

tribal organization under a 638 agreement, which

provides diagnostic, therapeutic (surgical and non-

surgical), and rehabilitation services to tribal members

admitted as inpatients or outpatients.

Prison/Correctional

Facility

A prison, jail, reformatory, work farm, detention center,

or any other similar facility maintained by either Federal,

State, or local authorities for the purpose of confinement

or rehabilitation of adult or juvenile criminal offenders.

Unassigned

N/A

Office

Location, Other than a Hospital, Skilled Nursing Facility,

Military treatment Facility, Community Health Center,

State or Local Public Health Clinic, or Intermediate Care

Facility, where the health professional routinely provides

health examinations, diagnosis, and treatment of illness

or injury on an ambulatory basis.

Home

Location, other than a Hospital or other Facility, where

the patient receives care in a private session.

Assisted Living

Facility

Congregate residential facility with self-contained living

units providing assessment of each resident’s needs and

on-site support 24-hours a day, seven (7) days a week,

with the capacity to deliver or arrange for services

including some healthcare and other services.

Group Home

A residence, with shared living areas, where clients

receive supervision and other services such as social and

/ or behavioral services, custodial service, and minimal

services (e.g., medication administration.

Mobile Unit

A facility / unit that moves from place-to-place equipped

to provide preventive, screening, diagnostic, and / or

treatment services.

Temporary Lodging

A short term accommodation such as a hotel, camp

ground, hostel, cruise ship or resort where the patient

receives care, and which is not identified by any other

POS code.

Common Billing Information ____________________________________________________

Ch. 6 Index 58 Revision 4/1/17

Place

Service

Place of Service Name

Place of Service Description

Walk-in Retail

Health Clinic

A walk-in-health clinic, other than an office, urgent care

facility, pharmacy or independent clinic and not

described by any other Place of Service code, that is

located within a retail operation and provides, on an

ambulatory basis, preventive and primary care services.

Place of

Employment-

Worksite

A location, not described by any other POS code, owned

or operated by a public or private entity where the patient

is employed, and where a health professional provides

on-going or episodic occupational medical, therapeutic or

rehabilitative services to the individual.

Unassigned

N/A

Urgent Care Facility

Location, distinct from a hospital emergency room, an

office, or a clinic, whose purpose is to diagnose and treat

illness or injury for unscheduled, ambulatory patients

seeking immediate medical attention.

Inpatient Hospital

A facility, other than psychiatric, which primarily

provides diagnostic, therapeutic (both surgical and non-

surgical), and rehabilitation services by, or under, the

supervision of physicians to patients admitted for a

variety of medical conditions.

Outpatient Hospital

A portion of a Hospital, which provides diagnostic,

therapeutic (both surgical and non-surgical), and

rehabilitation services to sick or injured persons who do

not require Hospitalization or Institutionalization.

Emergency Room –

Hospital

A portion of a Hospital where emergency diagnosis and

treatment of illness or injury is provided.

Ambulatory Surgical

Center

A free standing facility, other than a physician’s office,

where surgical and diagnostic services are provided on an

ambulatory basis.

Birthing Center

A facility, other than a hospital’s maternity facilities or a

physician’s office, which provides a setting for labor,

delivery, and immediate post-partum care as well as

immediate care of new born infants.

Military Treatment

Facility

A medical facility operated by one (1) or more of the

Uniformed Services. Military Treatment Facility (MTF)

also refers to certain former U.S. Public Health Services

(USPHS) facilities now designated as Uniformed Service

Treatment Facilities (USTF).

27-30

Unassigned

N/A

Common Billing Information ____________________________________________________

Ch. 6 Index 59 Revision 4/1/17

Place

Service

Place of Service Name

Place of Service Description

Skilled Nursing

Facility

A facility, which primarily provides inpatient skilled,

nursing care and related services to patients who require

medical, nursing, or rehabilitation services but does not

provide the level of care of treatment available on a

hospital.

Nursing Facility

A facility which primarily provides to residents skilled

nursing care and related services for the rehabilitation of

injured, disabled, or sick persons, or, on a regular basis,

health-related care services above the level of custodial

care to other than mentally retarded individuals.

Custodial Care

Facility

A facility which provides room, board and other personal

assistance services, generally on a long-term basis, which

does not include a medical component.

Hospice

A facility, other than a patient’s home, in which palliative

and supportive care for terminally ill patients and their

families are provided.

35-40

Unassigned

N/A

Ambulance – Land

A land vehicle specifically designed, equipped and

staffed for lifesaving and transporting the sick or injured.

Ambulance – Air or

Water

An air or water vehicle specifically designed, equipped

and staffed for lifesaving and transporting the sick or

injured.

43-48

Unassigned

N/A

Independent Clinic

A location, not part of a hospital and not described by

any other Place of Service code, that is organized and

operated to provide preventive, diagnostic, therapeutic,

rehabilitative, or palliative services to outpatients only.

Federally Qualified

Health Center

A facility located in a medically underserved area that

provides Medicare beneficiaries preventive primary

medical care under the general direction of a physician.

Inpatient Psychiatric

Facility

A facility that provides inpatient psychiatric services for

the diagnosis and treatment of mental illness on a 24-

hour basis, by or under the supervision of a physician.

Psychiatric Facility-

Partial

Hospitalization

A facility for the diagnosis and treatment of mental

illness that provides a planned therapeutic program for

patients who do not require full time hospitalization, but

who need broader programs than are possible from

outpatient visits to a hospital-bases or hospital-affiliated

facility.

Common Billing Information ____________________________________________________

Ch. 6 Index 60 Revision 4/1/17

Place

Service

Place of Service Name

Place of Service Description

Community Mental

Health Center

A facility that provides the following services: Outpatient

services, including specialized outpatient services for

children, the elderly, individuals who are chronically ill,

and residents of the CMHC’s mental health services are

who have been discharged from inpatient treatment at a

mental health facility; 24-hour a day emergency care

services; day treatment, other partial hospitalization

services, or psychosocial rehabilitation services.

Intermediate Care

Facility / Mentally

Retarded

A facility which primarily provides health-related care

and services above the level of custodial care to mentally

retarded individuals but does not provide the level of care

or treatment available in a hospital or SNF.

Residential

Substance Abuse

Treatment Facility

A facility which provides treatment for substance

(alcohol and drug) abuse to live-in residents who do not

require acute medical care. Services include individual

and group therapy and counseling, family counseling,

laboratory test, drugs and supplies, psychological testing,

and room and board.

Psychiatric

Residential

Treatment Center

A facility or distinct part of a facility for psychiatric care

which provides a total 24-hour therapeutically planned

and professionally staffed group living and learning

environment.

Non-residential

Substance Abuse

Treatment Facility

A location which provides treatment for substance

(alcohol and drug) abuse on an ambulatory basis.

Services include individual and group therapy and

counseling, family counseling, laboratory tests, drugs and

supplies, and psychological testing.

58-59

Unassigned

N/A

Mass Immunization

Center

A location where providers administer pneumococcal

pneumonia and influenza virus vaccinations and submit

these services as electronic media claims, paper claims,

or using the roster billing method. This generally takes

place in a mass immunization setting, such as, a public

health center, pharmacy, or mall but may include a

physician office setting.

Comprehensive

Inpatient

Rehabilitation

Facility

A facility that provides comprehensive rehabilitation

services under the supervision of a physician to inpatients

with physical disabilities. Services include physical

therapy, occupational therapy, speech therapy, speech

pathology, social or psychological services, and orthotics

and prosthetics services.

Common Billing Information ____________________________________________________

Ch. 6 Index 61 Revision 4/1/17

Place

Service

Place of Service Name

Place of Service Description

Comprehensive

Outpatient

Rehabilitation

Facility

A facility that provides comprehensive rehabilitation

services to outpatients with physical disabilities. Services

include physical therapy, occupational therapy, and

speech pathology services.

63-64

Unassigned

N/A

End-Stage Renal

Disease Treatment

Facility

A facility other that a hospital, which provides dialysis

treatment, maintenance, and /or training to patients or

caregivers on an ambulatory or home-care basis.

66-70

Unassigned

N/A

Public Health Clinic

A facility maintained by either State or local health

departments that provide ambulatory primary medical

care under the general direction of a physician.

Rural Health Clinic

A certified facility, which is located in a rural medically,

underserved area that provides ambulatory primary

medical care under the general direction of a physician.

73-80

Unassigned

N/A

Independent

Laboratory

A laboratory certified to perform diagnostic and/or

clinical tests independent of an institution or a

physician’s office.

82-98

Unassigned

N/A

Other Place of

Service

Other place of service not listed above.

6.5 Medicare Crossovers

Medicaid processes claims for Medicare/Medicaid services when provided to a

Medicaid eligible client.

6.5.1 General Information

 Dually eligible clients are clients that are eligible for Medicare and Medicaid.

 Providers may verify Medicare and Medicaid eligibility through the IVR (2.1,

Quick Reference).

 Providers must accept assignment of claims for dually eligible clients.

 Be sure Wyoming Medicaid has record of all applicable NPIs under which the

provider is submitting to Medicare to facilitate the electronic crossover

process.

 Medicaid reimburses the lesser of the assigned coinsurance and deductible

amounts or the difference between the Medicaid allowable and the Medicare

paid amount for dually eligible clients as indicated on the Medicare

(Explanation of Medicare Benefits) EOMB.

Common Billing Information ____________________________________________________

Ch. 6 Index 62 Revision 4/1/17

o Wyoming Medicaid’s payment is payment in full. The client is not

responsible for any amount left over, even if assigned to coinsurance

or deductible by Medicare.

6.5.2 Billing Information

 Medicare is primary to Medicaid and must be billed first. Direct Medicare

claims processing questions to the Medicare carrier.

 When posting the Medicare payment, the EOMB (Explanation of Medicare

Benefits) may state that the claim has been forwarded to Medicaid. No further

action is required, it has automatically been submitted.

 Medicare transmits electronic claims to Medicaid daily. Medicare transmits all

lines on a claim with any Medicare paid claim – If one (1) line pays, and three

(3) others are denied by Medicare, all four (4) lines will be transmitted to

Wyoming Medicaid.

 The time limit for filing Medicare crossover claims to Medicaid is 12-months

from the date of service or six (6) months from the date of the Medicare

payment, whichever is later.

 If payment is not received from Medicaid after 45-days of the Medicare

payment, submit a claim to Medicaid and include the COB (Coordination of

Benefits) information in the electronic claim. The line items on the claim

being submitted to Medicaid must be exactly the same as the claim submitted

to Medicare, except when Medicare denies then the claim must conform to

Medicaid policy.

 If a paper claim is being submitted, the EOMB must be attached. If the

Medicare policy is a replacement/advantage or supplement, this information

must be noted (it can be hand written) on the EOMB.

NOTE: Do not resubmit a claim for coinsurance or deductible amounts unless the

provider has waited 45-days from Medicare’s payment date. A provider’s

claims may be returned if submitted without waiting the 45-days after the

Medicare payment date.

Common Billing Information ____________________________________________________

Ch. 6 Index 63 Revision 4/1/17

6.6 Examples of Billing

6.6.1 Client has Medicaid Coverage Only or Medicaid and Medicare

Coverage

NOTE: When client has dual coverage, (Medicaid and Medicare) attach the

EOMB to the claim.

Common Billing Information ____________________________________________________

Ch. 6 Index 64 Revision 4/1/17

6.6.2 Client has Medicaid and Third Party Liability (TPL) or Client

has Medicaid, Medicare and TPL

NOTE: If the client has both Medicare and TPL in addition to Medicaid, attach the

TPL EOB and the Medicare EOMB to the claim. If the client has TPL and

Medicaid but no Medicare, attach the TPL EOB to the claim.

Common Billing Information ____________________________________________________

Ch. 6 Index 65 Revision 4/1/17

6.7 National Drug Code (NDC) Billing Requirement

Effective for dates of service on and after March 1, 2008 Medicaid will require

providers to include National Drug Codes (NDCs) on professional and institutional

claims when certain drug-related procedure codes are billed. This policy is mandated

by the Federal Deficit Reduction Act (DRA) of 2005, which requires state Medicaid

programs to collect rebates from drug manufacturers when their products are

administered in an office, clinic, hospital or other outpatient setting.

The NDC is a unique 11-digit identifier assigned to a drug product by the

labeler/manufacturer under Federal Drug Administration (FDA) regulations. It is

comprised of three (3) segments configured in a 5-4-2 format.

Labeler Code Product Code Package Code

(5 Digits) (4 Digits) (2 Digits)

 Labeler Code – Five (5) digit number assigned by the Food and Drug

Administration (FDA) to uniquely identify each firm that manufactures,

repacks, or distributes drug products.

 Product Code – Four (4) digit number that identifies the specific drug,

strength and dosage form.

 Package Code – Two (2) digit number that identifies the package size.

6.7.1 Converting 10-Digit NDC’s to 11-Digits

Many NDCs are displayed on drug products using a ten (10) digit format. However,

to meet the requirements of the new policy, NDCs must be billed to Medicaid using

the 11-digits FDA standard. Converting an NDC from ten (10) to 11-digits requires

the strategic placement of a zero (0). The following table shows three (3) common ten

(10) digit NDC formats converted to 11-digits.

Converting 10-Digit NDCs to 11-Digits

10-Digit Format

Sample 10-Digit

NDC

Required 11-Digit Format

Sample 10-Digit NDC

Converted to 11-Digits

9999-9999-99 (4-4-2)

0002-7597-01 Zyprexa

10mg vial

09999-9999-99 (5-4-2)

00002-7597-01

99999-999-99 (5-3-2)

50242-040-62 Xolair

150mg vial

99999-0999-99 (5-4-2)

50242-0040-62

99999-9999-9 (5-4-1)

60575-4112-1 Synagis

50mg vial

99999-9999-09 (5-4-2)

60575-4112-01

Common Billing Information ____________________________________________________

Ch. 6 Index 66 Revision 4/1/17

NOTE: Hyphens are used solely to illustrate the various ten (10) and 11 digit

formats. Do not use hyphens when billing NDCs.

6.7.2 Documenting and Billing the Appropriate NDC

A drug may have multiple manufacturers so it is vital to use the NDC of the

administered drug and not another manufacturer’s product, even if the chemical name

is the same. It is important that providers develop a process to capture the NDC when

the drug is administered, before the packaging is thrown away. It is not permissible to

bill Medicaid with any NDC other than the one (1) administered. Providers should not

pre-program their billing systems to automatically utilize a certain NDC for a

procedure code that does not accurately reflect the product that was administered to

the client.

Clinical documentation must record the NDC from the actual product, not just from

the packaging, as these may not match. Documentation must also record the lot

number and expiration date for future reference in the event of a health or safety

product recall.

Common Billing Information ____________________________________________________

Ch. 6 Index 67 Revision 4/1/17

6.7.3 Procedure Code/NDC Combinations

The list of rebateable NDCs Medicaid posts to its website will also present providers

a way to validate procedure code/NDC combinations. The table below illustrates a

few sample entries from the list.

NDC

Procedure

Code

Procedure

Description

NDC Label

Rebateable

Rebate

Start

Date

Rebate

End

Date

58468-

0040-01

J0180

Injection,

Agalsidase

Beta, 1 MG

Fabrazyme (PF)

35 MG

01/01/1991

99/99/9999

58468-

0041-01

J0180

Injection,

Agalsidase

Beta, 1 MG

Fabrazyme (PF)

5 MG

01/01/1991

99/99/9999

58468-

1060-01

J0205

Injection,

Alglucerase,

Per 10

Ceredase 80

U/ML

01/01/1991

99/99/9999

00517-

8905-01

J0210

Injection,

Methyldopa

te HCL

Methyldopate

HCL (S.D.V.) 50

10/01/1991

99/99/9999

The first two (2) entries show NDCs 58468-0040-01 and 58468-0041-01 can only be

paired with one (1) procedure code, J0180. These are the only valid procedure code /

NDC combinations when billing Agalsidase. Pairing either NDC with a different

procedure code OR pairing the procedure code with a different NDC would create an

invalid combination. Procedure code / NDC combinations deemed invalid according

to the list will be denied.

6.7.4 Billing Requirements

The requirement to report NDCs on professional and institutional claims is meant to

supplement procedure code billing, not replace it. Providers are still required to

include applicable procedure code information such as dates of service, CPT/HCPCS

code, modifier(s), charges and units.

6.7.5 Submitting One NDC per Procedure Code

If one (1) NDC is to be submitted for a procedure code, the procedure code,

procedure quantity and NDC must be reported. No modifier is required.

Procedure Code

Modifier

Procedure Quantity

NDC

90378

60574-4111-01

Common Billing Information ____________________________________________________

Ch. 6 Index 68 Revision 4/1/17

6.7.6 Submitting Multiple NDCs per Procedure Code

If two (2) or more NDCs are to be submitted for a procedure code, the procedure code

must be repeated on separate lines for each unique NDC. For example, if a provider

administers 150 mg of Synagis, a 50 mg vial and a 100 mg vial would be used.

Although the vials have separate NDCs, the drug has one (1) procedure code, 90378.

So, the procedure code would be reported twice on the claim, but paired with

different NDCs.

Procedure Code

Modifier

Procedure Quantity

NDC

90378

60574-4111-01

90378

60574-4112-01

On the first (1st) line, the procedure code, procedure quantity, and NDC are reported

with a KP modifier (first drug of a multi-drug). On the second line, the procedure

code, procedure quantity and NDC are reported with a KQ modifier

(second/subsequent drug of a multi-drug).

NOTE: When reporting more than two (2) NDCs per procedure code, the KQ

modifier is also used on the subsequent lines.

6.7.7 Medicare Crossover Claims

Because Medicaid pays Medicare coinsurance and deductible for dual-eligible clients,

the NDC will also be required on Medicare crossover claims for all applicable

procedure codes. Medicaid has verified that NDC information reported on claims

submitted to Medicare will be included in the automated crossover claim feed to

Medicaid. Crossover claim lines that are missing a required NDC will be denied.

6.7.8 CMS-1500 02-12 Billing Instructions

To report a procedure code with a NDC on the CMS-1500 02-12 claim form, enter

the following NDC information into the shaded portion of field 24A:

 NDC qualifier of N4 [Required]

 NDC 11-digit numeric code [Required]

Do not enter a space between the N4 qualifier and the NDC. Do not enter hyphens or

spaces within the NDC.

CMS-1500 02-12 – One (1) NDC per Procedure Code:

Common Billing Information ____________________________________________________

Ch. 6 Index 69 Revision 4/1/17

CMS-1500 02-12 – Two (2) NDCs per Procedure Code:

NOTE: Medicaid’s instructions follow the National Uniform Claim Committee’s

(NUCC) recommended guidelines for reporting the NDC on the CMS-

1500 02-12 claim form. Provider claims that do not adhere to these

guidelines will be returned unprocessed.

6.8 Cap Limits

Medicaid clients 21 years of age and older are subject to service cap limits on the

number of office/outpatient hospital visits and behavioral health visits. Medicaid

clients of any age are subject to service cap limits on the number of

physical/occupational/speech therapy visits, chiropractic visits, dietician visits and

emergency dental visits they receive.

NOTE: Ancillary services (e.g., lab, x-ray, etc.) provided during an

office/outpatient hospital visit that exceeded the cap limit will still be

reimbursed.

OFFICE AND OUTPATIENT HOSPITAL VISITS

Codes

Limits

Does not apply to:

Procedure Codes:

99281-99285

99201-99215

Revenue Codes:

0450-0459

0510-0519

12 combined visits per

calendar year

 Clients Under Age 21

 Emergency Visits

 Family Planning Services

 Medicare Crossovers

Common Billing Information ____________________________________________________

Ch. 6 Index 70 Revision 4/1/17

PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY,

BEHAVIORAL HEALTH VISITS, CHIROPRACTIC VISITS AND DIETICIAN

Codes

Limits

Does not apply to:

Procedure codes:

90785; 90792; 90832-

90834; 90836-90839;

90845-90849; 90853;

90857;92507-92508;

92526; 96101-96125;

97010-97039; 97110-

97546, 97802-97804,

98940-98942; (all

modalities on same date of

service count as 1 visit)

HCPCS Level II codes:

G9012; H0005-H0006;

H0031; H0034; H0047;

H2010; H2014; H2015;

H2017; H2019; H2021;

T1007; T1012; T1017 (all

modalities on same date of

service count as 1 visit)

Revenue codes:

0420,0421, 0422,0 424,

0430, 0431, 0432, 0434,

0439, 0440, 0441, 0442,

0444, and 0449 (each unit

counts as 1 visit)

20 physical therapy

visits per calendar year

20 occupational therapy

visits per calendar year

20 speech therapy visits

per calendar year

20 behavioral health

visits per calendar year

(21 and over only)

20 chiropractic visits per

calendar year

20 dietician visits per

calendar year

Medicare Crossovers

If a client has exceeded the Medicaid limits on office/outpatient hospital visits,

physical/occupational/speech therapy visits, behavioral health visits, chiropractic

visits, or dietitian visits the provider may bill him/her or request the cap limit be

waived.

6.8.1 Cap Limit Waiver

Physicians, nurse practitioners, physical, occupational and speech therapists,

psychiatrist, psychologists, licensed mental health professionals such as licensed

professional counselors, licensed marriage and family therapist, licensed certified

social workers and licensed addiction therapists, community mental health or

substance abuse treatment centers, chiropractors and dieticians may request a waiver

of a cap limit once a limit has been reached.

Common Billing Information ____________________________________________________

Ch. 6 Index 71 Revision 4/1/17

Cap limit waiver requests must be submitted on the Cap Limit Waiver Request form

and cite specific medical necessity. Below is the Cap Limit Waiver Request form for

office visits, therapies (PT, OT, ST and Chiropractic services), dietician visits and

Behavioral Health visits (6.9.2 Cap Limit Waiver Request Form).

The form must be mailed to:

Wyoming Medicaid

Attn: Medical Policy

PO Box 667

Cheyenne, WY 82003-0667

If granted, a cap limit waiver is valid for one (1) calendar year. For additional

information, contact Medical Policy (2.1, Quick Reference).

If a cap limit waiver request is denied, the provider may request reconsideration by

mail by providing additional supporting documentation to include but not limited to a

detailed letter of explanation as to why you feel the denial is incorrect, additional

medical records and/or testing results. This request must be in accordance with

Medicaid rules.

6.8.2 Cap Limit Waiver Request Form

NOTE: Click image above to be taken to a printable version of this form

Common Billing Information ____________________________________________________

Ch. 6 Index 72 Revision 4/1/17

6.8.3 Cap Limit Waiver Request Form Instructions

Field

Action

Pay to (Group) NPI

Complete with the ten digit NPI number for the Pay to/Group Provider

Pay to (Group) Name

Complete with the name of the Pay to/Group Provider

Treating/Rendering NPI

Complete with the ten digit NPI number for the treating provider

Treating/Rendering Name

Complete with the name of the treating provider

Client ID

Complete with the client’s Wyoming Medicaid ID number

Client Name

Complete with the client’s full name

Client Age

Complete with the client’s age at the time of the request

Cap Limit Year

Complete with the requested calendar year for the cap limit waiver

Cap Limit Begin/End Date

Complete with the dates the cap limit waiver will need to begin and when

it will end

Cap Limit Type

Check the appropriate box for which type cap limit waiver you are

requesting

Date of Onset Condition

Complete with the date the onset condition began

Diagnosis Code

Complete with the diagnosis codes – up to four are allowed

Ordering Provider Name & NPI

Complete with the Name and NPI number for the ordering provider – this

section is required for Speech, Occupational or Physical Therapy

Describe injury, illness, surgery or

triggering event that initiated the

need for services

Complete with what caused the acute condition (i.e. post-surgery,

personal injury, auto accident, etc.)

Describe acute condition requiring

rehabilitative services

A detailed explanation as to the diagnosis and rehabilitative need for

services for acute conditions only. Indicate why the client has exceeded

their CAP limit. For Behavioral Health Cap Limit Waiver Request,

ensure to include last 5 progress reports and treatment plan.

Describe anticipated rehabilitative

progress and length of additional

treatment

Describe the rehabilitative progress anticipated and the length needed for

additional treatment. For physical, occupational, or speech therapy Cap

Limit Waiver Requests, ensure you attach a copy of the practitioner’s

order.

Treating provider signature and date

The provider providing the services will need to sign and date the Cap

Limit Waiver Request Form

Common Billing Information ____________________________________________________

Ch. 6 Index 73 Revision 4/1/17

6.8.4 Cap Limit Additional Information for Clients Under the Age of 21

In addition to the completion of the Cap Limit Waiver Request Form, the Additional

Information sheet must be completed for clients under the age of 21.

Common Billing Information ____________________________________________________

Ch. 6 Index 74 Revision 4/1/17

6.8.5 Cap Limit Additional Information Instructions

Cap Limit Additional Information

For Children who are school age:

Field

Action

Is this child on IEP?

Indicate whether or not the child is on an Individualized Education Program (IEP)

What services is the

child receiving

through school

system?

Describe the services the child is receiving through the school system under the IEP

How are the

services you are

provider distinct

from the services

being provided

through the school

system and how are

you avoiding

conflict with the

services being

provided?

Describe how the services you are providing to the client are different from the

services that are being provided through the school system and how you are avoiding

conflict with those services

For kids who are younger than school age

Has this child been

evaluated at a Child

Development

Center?

Indicate whether or not this child has been evaluated at a Child Development Center

(CDC)

What services is the

child receiving

through the CDC?

Describe the services the child is receiving through the Child Development Center

How are the

services you are

providing distinct

from the services

being provided

through the CDC

and how are you

avoiding conflict

with the services

being provided?

Describe the services you are providing and how they are distinct from the services

that are being provided through the Child Development Center and how you are

avoiding conflict with those services being provided through the CDC

Common Billing Information ____________________________________________________

Ch. 6 Index 75 Revision 4/1/17

6.9 Reimbursement Methodologies

Medicaid reimbursement for covered services is based on a variety of payment

methodologies depending on the service provided.

 Medicaid fee schedule

 By report pricing

 Billed charges

 Invoice charges

 Negotiated rates

 Per diem

 RBRVS (Resource Based Relative Value Scale)

6.10 Usual and Customary Charges

Charges for services submitted to Medicaid must be made in accordance with an

individual provider’s usual and customary charges to the general public unless:

 The provider has entered into an agreement with the Medicaid Program to

provide services at a negotiated rate; or

 The provider has been directed by the Medicaid Program to submit charges at

a Medicaid-specified rate.

6.10.1 Invoice Charges

 Invoice must be dated within 12-months prior to the date of service being

billed – if the invoice is older, a letter must be included explaining the age of

the invoice (i.e. product purchased in large quantity previously, and is still in

stock)

 All discounts will be taken on the invoice.

 The discounted pricing or codes cannot be marked out.

 A packing slip, price quote, purchase order, delivery ticket, etc. may be used

only if the provider no longer has access to the invoice, and is unable to obtain

a replacement from the supplier/manufacturer, and a letter with explanation is

included.

 Items must be clearly marked. (i.e. how many calories are in a can of formula,

items in a case, milligrams, ounces, etc.)

Common Billing Information ____________________________________________________

Ch. 6 Index 76 Revision 4/1/17

6.11 Co-Payment Schedule

$2.45 Co-Payment Schedule

Procedure and

Revenue Code(s)

Description

Exceptions

99201 – 99215

Office Visits only when the place

of service code is 11

Co-payment requirements do not

apply to:

 Clients under age 21

 Nursing Facility Residents

 Pregnant Women

 Family planning services

 Emergency services

 Hospice services

 Medicare Crossovers

 Members of a Federally recognized

tribe

99341 -99350

Home Visits

92002, 92004,

92014

Eye Examinations

90804 – 90815

Medical psychotherapy – co-

payment only applies when the

place of service code is 11

6.12 How to Bill for Newborns

When a mother is eligible for Medicaid, at the time the baby is born, the newborn is

automatically eligible for Medicaid for one (1) year. However, the WDH Customer

Service Center must be notified of the newborn’s name, gender, and date of birth,

mom’s name and Medicaid number for a Medicaid ID Card to be issued. This

information can be faxed, emailed, or mailed to the WDH Customer Service Center

on letterhead from the hospital where the baby was born or reported by the parent of

the baby. A provider will need to have the newborn client ID in order to bill newborn

claims.

6.13 Prior Authorization

Medicaid requires prior authorization (PA) on selected services and equipment.

Approval of a PA is never a guarantee of payment. A provider should not render

services until a client’s eligibility has been verified and a PA has been approved (if a

PA is required). Services rendered without obtaining a PA (when a PA is required)

may not be reimbursed.

Selected services and equipment requiring prior authorization include, but are not

limited to, the following – use in conjunction with the Medicaid Fee Schedule to

verify what needs PA: