048-11 Wyo. Code R. § 11-5
Except as otherwise specified in this Chapter or Chapter 1, the terminology used in this Chapter is the standard terminology and has the standard meaning used in health care, Medicaid, and Medicare.
The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indicates that such is the intent, words in the singular number shall include the plural and vice versa.
For the purpose of these rules, the following shall apply:
(a) "Certification of medical necessity." A written certification by the prescribing practitioner certifying that the equipment is medically necessary, for items identified by the Department.
(i) The Department may, from time to time, designate equipment as requiring a certification of medical necessity based on clinical consultation with health professionals, CMS guidelines, and other appropriate sources. The Department shall disseminate to providers a current list of the equipment which requires a certification of medical necessity through Provider Manuals or Provider Bulletins; and
(ii) A certification of medical necessity is in addition to a physician's order.
(b) "Disposable Medical Supplies (supplies)." Supplies prescribed by a practitioner which have a medical purpose, are specifically related to the active treatment or therapy of the recipient for a medical illness or physical condition and which are consumable and/or expendable and non-durable. Supplies must meet the definition of medically necessary and shall be prescribed by an appropriate licensed practitioner.
(c) "Excess payments." Medicaid funds received by a provider, to which the provider is not entitled for any reason, including payments which exceed the Medicaid allowable payment. "Excess payments" includes, but is not limited to:
(i) Overpayments;
(ii) Payments made as a result of system errors;
(iii) Payments for services furnished to a non-recipient;
(iv) Payments for non-covered services furnished to a recipient;
(v) Payments for services which are not documented and/or supported by medical records and/or financial records;
(vi) Payments for services for which admission certification has been denied or withdrawn;
(vii) Payments which exceed a provider's usual and customary charge, unless otherwise permitted by the Department's rules.
(d) "Misuse." The intentional utilization of equipment, prosthetic device, or supplies in a manner not prescribed or re commended, resulting in the need for repairs or replacement; or utilization by persons other than that for whom the use is prescribed or intended according to Department records.
(e) "Practitioner's order." A written order which:
(i) Is on a practitioner's personalized prescription pad or the practitioner's letterhead, either of which must contain the practitioner's printed name;
(ii) Contains the practitioner's personal signature (a stamped signature or a practitioner's signature written by another person are not acceptable), and the date it is signed;
(iii) Contains one or more diagnosis codes or a statement of the condition which necessitates the medical supplies or equipment, and an estimate, in days, months, or years, of the time it will be needed;
(iv) In the case of durable medical equipment or a prosthetic device, specifies the additional or optional features which will be separately billed using HCPCS codes;
(v) In the case of medical supplies, specifies the quantity and frequency of use, the frequency of changes, and the estimated duration of medical necessity; and
(vi) Is reviewed and re-signed by the practitioner at least once per year.
(f) "Prescribed." Ordered by a practitioner to be furnished to a client to treat a medical condition. Medical supplies or durable medical equipment which are prescribed must be on a practitioner's order.
(g) "Prosthetic Devices." Replacement, corrective, or supportive devices prescribed by a practitioner to:
(i) Artificially replace a missing portion of the body;
(ii) Prevent or correct physical deformity or malfunction; or
(iii) Support a weak or deformed portion of the body.
(h) "Service area." The State of Wyoming and the following cities or towns: Craig, Colorado; Idaho Falls, Montpelier and Pocatello, Idaho; Billings and Bozeman, Montana; Kimball and Scottsbluff, Nebraska; Belle Fourche, Custer, Deadwood, Rapid City and Spearfish, South Dakota; and Ogden and Salt Lake City, Utah.
048-11 Wyo. Code R. § 11-5
Amended, Eff. 2/8/2017.