Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 11 - MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, AND PROSTHETICS
Section 11-8 - General Coverage Provisions

Universal Citation: WY Code of Rules 11-8

Current through September 21, 2024

(a) The medical supplies, durable medical equipment, and prosthetics described in Sections 9 and 10 are a covered service if they are:

(i) Medically necessary, as defined in Wyoming Medicaid Rules Chapter 1;

(ii) Appropriate and effective for the client's medical needs;

(iii) Timely, considering the nature and present medical condition of the client;

(iv) Provided by a provider with appropriate credential;

(v) The least expensive, appropriate alternative available;

(vi) Not considered experimental or investigational;

(vii) An effective and appropriate use of Medicaid funds;

(viii) Suitable for use in the client's home or any non-institutional setting in which normal life activities take place;

(ix) Generally not useful in the absence of an illness, injury, or disability;

(x) Provided to correct or accommodate a physiological disorder of physical condition, or generally used primarily for a medical purpose; and,

(xi) Prescribed using a practitioner's order which:
(A) Includes one or more diagnosis codes, or a statement of the condition which necessitates the medical supplies, durable medical equipment or prosthetics, and an estimate in days, months, or years of the time it will be needed;

(B) If durable medical equipment or a prosthetic device, specifies the additional or optional features which will be separately billed using HCPCS codes;

(C) If medical supplies, specifies the quantity and frequency of use, the frequency of changes, the estimated duration of medical necessity, and is reviewed and re-signed by the practitioner at least once per year.

(b) The Department may designate certain durable medical equipment as requiring a certification of medical necessity in addition to a practitioner's order based on clinical consultation with health professionals, CMS guidelines, and other appropriate sources. The Department shall disseminate to providers a current list of the durable medical equipment which requires a certification of medical necessity through applicable provider manuals and bulletins.

(c) Providers shall be responsible for the delivery of the prescribed medical supplies, durable medical equipment, and prosthetics.

(d) After delivery, if an item is determined to be inappropriate or incorrect, the provider is responsible for retrieving the medical supplies or durable medical equipment within five (5) working days after being notified of the problem by the client or the Department.

(i) Claims for items known to be awaiting pickup by the provider cannot be billed to the Medicaid program.

(ii) If billing occurs prior to notice that pickup is necessary, the provider shall submit an adjustment within twenty (20) working days following the date of pickup.

(e) Providers shall be responsible for confirmation of continued need for disposable supplies by contact with the client or client's caregiver prior to shipment of supplies. Continued need shall be confirmed by a current prescription which contains the duration of medication necessity.

Disclaimer: These regulations may not be the most recent version. Wyoming may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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