Section 12-8 - Prior Authorization (a) Prior authorization of home health services shall be governed by Chapter 3.
(b) All home health services require prior authorization.
(c) The failure to obtain prior authorization shall result in the denial of Medicaid payment for the service.
(d) The provider shall submit the following as part of the prior authorization request. - (i) Submission of plan of treatment. The provider shall submit a written request for prior authorization on the forms specified by the Department, including the plan of treatment, before the submission of a claim for such services. The Department may request additional information as necessary to review the plan of treatment.
- (A) The plan of treatment shall include a statement that the home health services are appropriate and medically necessary.
- (B) The plan of treatment shall be reviewed, signed, and dated by the attending physician at least once every sixty (60) days.
- (ii) Face to face visit. All new home health orders shall be accompanied by documentation of a face to face visit having occurred between the client and the attending physician (ordering provider) within the ninety (90) days prior to the start of home health services.
- (iii) Documentation of Medicare status. For clients eligible under both Wyoming Medicaid and Medicare, documentation from the ordering provider shall be included indicating the client is not home-bound and would not qualify for home health services under their Medicare benefits.
- (iv) The Department or their designee may request additional information as necessary to review the prior authorization.
(e) Denial of plan of treatment. If a plan of treatment is disapproved, the provider may submit a revised plan of treatment or additional documentation as necessary for the Department's reconsideration.
048-12 Wyo. Code R. § 12-8