(a) Verify and
obtain information. At the time a client requests services from a provider, the
provider shall review the client's eligibility card for information regarding
third party payers. The provider shall ask the client if the information on the
card is current and whether there are or may be additional third party payers.
If the provider learns of a potential third party payer that is not listed on
the eligibility card, the provider shall notify the Department in writing of
that information within thirty (30) calendar days.
(b) Notify the Department of requests for
information. Release of information by providers for casualty related third
party resources not known to the State may be identified through requests for
medical reports and bills received by providers from attorneys, insurance
companies, and other parties. Providers shall contact the Department before
responding to such requests.
(c)
Notification of death.
(i) An institutional
provider shall notify the Department, in writing, of any client's death which
occurs in the facility or which occurs after the client is transported from the
provider's facility to another facility, such as a hospital or
hospice.
(ii) Time of notice. The
notification shall be sent to the Department on or before the end of the third
working day after the client's death.
(iii) Contents of notice. The notification
shall be in the form and contain the information required by the Department, as
specified in the Provider Manual.
(d) Billing. Unless otherwise provided by a
TPL waiver, this subsection shall govern the submission of bills involving
third party payers.
(i) When a provider is
informed that the client has or may have coverage by a third party payer, the
provider shall seek payment from the third party payer prior to submitting a
Medicaid claim. When the amount payable by the third party payer is less than
the allowable Medicaid payment, the provider may submit a Medicaid claim for
the difference. The Medicaid claim shall be accompanied by documentation of the
amount payable by the third party payer or submitted electronically with the
appropriate coordination of benefits information, including claims adjustment
reason and remark codes.
(ii) If a
third party payer rejects the request for payment, the provider may submit a
Medicaid claim to the Department. The provider shall attach a copy of the
notice of rejection to the Medicaid claim, upload a copy of the notice of
rejection to the Medicaid web portal to be linked to the corresponding
electronic claim, or submit the Medicaid claim electronically with the
appropriate coordination of benefits information, including claims adjustment
reason and remark codes.
(iii) If a
provider has not received payment or a rejection notice from a third party
payer within ninety (90) days after submitting two (2) requests or attempts for
payment, the provider may submit a Medicaid claim. The provider shall submit
with the Medicaid claim, copies of the requests for payment to the third party
payer, and any written communication the provider has received from the third
party payer.
(iv) A provider which
has received payment from a third party payer may submit a Medicaid claim. In
such cases the provider shall submit with the Medicaid claim documentation of
the payment received. The Department shall allow the Medicaid claim only to the
extent the allowable Medicaid reimbursement exceeds the payment received from
the third party payer and subject to the Department's normal procedures and
standards.
(v) A provider shall
submit Medicaid claims to the Department within twelve (12) months of the date
of service or discharge, whichever is later, regardless of the potential
involvement of a third party payer, except that Medicare crossover claims shall
be submitted within six (6) months after the date of payment or rejection by
Medicare. Medicaid claims submitted after the time limits specified in this
paragraph shall be rejected. Refer to Chapter 3 of the Medicaid rules for
further information.
(vi) For the
purposes of paragraph (d)(i) of this section, any amount paid by Medicaid when
combined with the amount paid by the third party payer, shall not exceed the
amount payable to the provider under any preferred provider or similar
agreement between the provider and that third party payer. The Department is
only responsible for the patient's responsibility.
(vii) A provider shall not opt-out of
participation with a third party payer. If a provider chooses to opt-out of
participation with a third party payer, the Department shall not pay for
services covered by, but not billed to, the third party payer. The provider
shall work with the third party payer or client to have the claim submitted to
the carrier.
(viii) If a provider
chooses to bill Wyoming Medicaid, the provider accepts Medicaid payment as
payment in full. The provider shall not bill Wyoming Medicaid and accept
payment and bill the other third party. The provider shall choose whether to
bill Wyoming Medicaid or bill the other party and wait for legal liability to
be established.
