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 3-5 - Provider Enrollment and Participation
Universal Citation: WY Code of Rules 3-5
Current through September 21, 2024
(a) The Department shall not pay Medicaid Funds to any individual or entity that provides services to a client unless the individual or entity is a party to a fully executed provider agreement and is enrolled by the Department.
(b) The following procedure governs the enrollment of providers in the Medicaid program:
(i) An individual or entity that wishes to
participate in the Medicaid program shall apply to be a provider on the forms
specified by the Department, and shall submit the qualifying documentation and
information required by the Department to be enrolled as a provider.
(ii) The Department or its designated agent
shall review and make a determination on the application within thirty (30)
calendar days of the date it receives the application and all necessary
qualification documentation, including any supplemental information requested
by the Department.
(iii) If the
application is approved, the provider and the Department shall execute a
provider agreement as specified by the Department.
(iv) If the application is denied, the
Department shall notify the applicant of its decision in writing in accordance
with Wyoming Medicaid Rules Chapter 4.
(c) The provider's enrollment shall become effective when all requisite state and federal verifications have been completed and the provider agreement has been fully executed. It shall remain in effect for five (5) years from the effective date of the provider agreement or until terminated. Enrollment may be renewed upon application.
(d) The Department may retroactively enroll an individual or entity as a provider that previously furnished services to a client.
(i) The Department may provide
Medicaid reimbursement for such services if the following requirements have
been met:
(A) The individual or entity
successfully applies to be a provider and states the requested effective date
of enrollment;
(B) The services are
otherwise reimbursable pursuant to Wyoming Medicaid Rules; and
(C) The individual or entity demonstrates it
was qualified to provide the services for which it seeks reimbursement at the
time services were delivered.
(ii) No Medicaid reimbursement shall be made
before the provider seeking such reimbursement has been enrolled by the
Department.
(e) Conditions of Provider's Participation.
(i) A
provider shall not discriminate against any individual on the basis of race,
color, religion, national origin, sex, disability, or age, except as allowed by
law.
(ii) A provider shall not
place restrictions or criteria on the services it will make available, the type
of health conditions it will accept, or the persons it will accept for care or
treatment, unless the provider applies those restrictions or criteria to all
individuals seeking the provider's services.
(iii) A provider may not refuse to furnish
services to a Medicaid client on account of a third party's potential liability
for the service(s).
(iv) A provider
shall comply with the Social Security Act, the Wyoming Medical Assistance and
Services Act, and all rules and regulations promulgated under those Acts. A
provider shall comply with other federal and state laws applicable to the
services offered by the provider to clients.
(v) A provider shall comply with applicable
licensing and certification standards found in Wyoming statutes and rules, or
in the statutes and regulations of the state in which the provider is located,
or in the statutes and regulations of the state in which the services are
provided. If applicable, a provider shall comply with Medicare certification
standards.
(vi) If acting as an
employer or contractor of personnel a provider entity shall ensure:
(A) Its personnel operate within the limits
and scope of practice allowed under the individual's professional licensure or
certification and within the limits of the entity's licensure or certification;
and
(B) It complies with the U.S.
Department of Health and Human Services, Office of Inspector General's
regulations and guidance on employment of individuals excluded from
participation in federally funded health care programs.
(vii) A provider shall comply with all
applicable state and federal laws in safeguarding information about applicants
and clients.
(f) Termination of Provider Enrollment.
(i) The
Department shall terminate a provider's enrollment if:
(A) The provider loses, or fails to provide
documentation of, required licensure or certification. The termination shall be
effective the same date the provider's license or certification status
changes;
(B) The provider is
excluded from participation in federally funded health care programs by the
U.S. Department of Health and Human Services, Office of Inspector General. The
termination shall be effective the same date the provider was excluded from the
federal programs;
(C) The provider
has been terminated from participation in Medicare when Medicare certification
is a prerequisite to enrollment in Medicaid. The duration of the provider's
termination for Medicaid shall be the same as and shall run contemporaneously
with the provider's termination from participation in Medicare. The provider's
remedies in regard to the termination under this subsection are limited to
those provided by Medicare; or
(D)
There was a finding of fraud, abuse, or other prohibited activities of the
provider by a judicial or administrative process where that provider was
afforded a notice and the right to a hearing.
(E) If a provider's enrollment is terminated
under this subsection it is not an adverse action as defined, and the
Department is not required to notify the provider in writing in accordance with
Wyoming Medicaid Rules Chapter 4.
(ii) The Department may terminate a
provider's enrollment pursuant to Wyoming Medicaid Rules Chapter 16. If a
provider's enrollment is terminated under this subsection the Department shall
notify the provider of the adverse action in writing in accordance with Wyoming
Medicaid Rules Chapter 4.
(g) The Department may reenroll a terminated provider if:
(i) The Department has been
reimbursed for all overpayments or a payment agreement is in effect;
(ii) The Department is satisfied that
sufficient safeguards have been implemented to ensure that the factors which
led to the termination will not recur; and
(iii) The provider successfully completes the
Medicaid enrollment process.
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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