Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 3 - PROVIDER ENROLLMENT AND PARTICIPATION, PRE-AUTHORIZATION, PAYMENT AND SUBMISSION OF CLAIMS BY PROVIDERS
Section 3-13 - Submission of Claims

Universal Citation: WY Code of Rules 3-13

Current through September 21, 2024

(a) The Department shall deny claims which are improperly submitted or which contain errors of any kind. Such claims may be resubmitted, subject to applicable federal and state requirements.

(b) A provider shall not bill the Department in excess of the provider's usual and customary charge for the service. The provider shall not bill the client or the Department for administrative fees such as standard processing or late fees.

(c) An individual provider shall not submit claims for reimbursement unless the services were rendered personally by that provider, or by an intern or resident while acting under the clinical supervision of that provider when allowed by applicable licensing or credentialing bodies. A provider entity shall not submit claims for reimbursement unless the services were rendered by qualified employed or contracted personnel acting under the supervision and control of the provider entity.

(d) A provider may seek Medicaid payment through a business agent for services furnished to a client by the provider if the business agent's compensation is related to the actual cost of processing the billing, is not related on a percentage or other basis to the amount of the claim, and is not dependent upon payment of the claim.

(e) A provider is responsible for all claims, whether submitted directly or through an agent, designee, employee or other intermediary.

(f) Any loss of Medicaid reimbursement caused by provider error is the responsibility of the provider and the provider may not bill the client for such services.

(g) A provider shall complete all required documentation, including required signatures, prior to claims submission to the Department. Documentation prepared or completed after the submission of the claim may be deemed by the Department or its designee as insufficient to substantiate the claim, in which case Medicaid funds shall be withheld or recovered.

(i) Claims shall be submitted to the Department in the manner and on the forms specified by the Department.

(ii) Claims shall include prior authorization number, if applicable, and

(iii) Claims shall include other documentation or records as the Department may request as outlined in the applicable Medicaid provider manual.

(iv) Claims submitted to the Department for standard processing, among other requirements shall include:
(A) Valid client identification (ID) number for the client of service;

(B) Valid provider NPI number and taxonomy for the service provided, including specification of the rendering provider as applicable;

(C) Valid billing and diagnosis codes as established by the Department;

(D) Appropriate billing code units as established by the Department; and,

(E) Other provider or specific claim fields as required for a "clean claim" by the Department.

(v) Any paid claim that does not meet the claims submission criteria established by the Department will be voided after appropriate provider notification. "Claim voids" conducted under this authority shall not be subject to reconsideration or the administrative hearing process described in Wyoming Medicaid Rules Chapter 4.

(vi) The Department shall deny claims not timely submitted. Claims shall be submitted and finalized on or before twelve (12) months after the date of service or the date of discharge, whichever is later, except for the following:
(A) Medicare cross-over claims shall be submitted within six (6) months after the date Medicare acts on the claim; or

(B) In the event of retroactive eligibility, such claims shall be submitted within six (6) months of the date of the determination of retroactive eligibility.

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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