Wyoming Administrative Code
Agency 048 - Health, Department of
Sub-Agency 0037 - Medicaid
Chapter 8 - INPATIENT HOSPITAL ADMISSION CERTIFICATION
Section 8-13 - Post-payment Reviews

(i) All procedural requirements of this Chapter were met;

(ii) The admission met the medical necessity criteria;

(iii) All appropriate services were provided;

(iv) All services provided were medically necessary and appropriate;

(v) All services were provided in conformance with prevailing norms of medical practice;

(vi) Diagnosis and procedure coding meets ICD and CPT; and

(vii) Revenue coding is appropriate.

(i) Once the records have been requested from the provider and received, a clinical evaluator shall review the medical record and shall review the claims involving such client.

(ii) If the clinical evaluator is unable to determine that the clients admission met the medical necessity criteria, that the clients continued stay met the medical necessity criteria, or that all medically necessary services were provided, the clinical evaluator may request additional information from the attending physician or the hospital as necessary to clarify the medical record. If the clinical evaluator determines that the procedural requirements of this Chapter were not met, the clinical evaluator shall follow Department policy.

(iii) If, after additional information is submitted, the clinical evaluator is unable to determine that the clients admission met the medical necessity criteria, or that all medically necessary services were provided, a physician adviser shall be consulted.

(iv) If a physician adviser determines that the clients admission was not medically necessary, or that all medically necessary services were not provided, the Department shall, if admission certification was previously granted, withdraw the admission PA.

(v) The Department shall notify the attending physician and hospital in writing that the admission certification is withdrawn, that no Medicaid payment will be made for inpatient hospital services, and that payments previously made for services which were not medically necessary shall be recovered.