(a) Completion of an evaluation of medical necessity. No facility shall receive Medicaid reimbursement for nursing facility services provided to a client until: - (i) The medical necessity evaluator has completed an evaluation of medical necessity which indicates that nursing facility services are medically necessary; and
- (ii) The nursing facility has complied with Chapter 19.
(b) Continued stay reviews for residents of nursing facilities. - (i) When a continued stay review indicates that nursing facility services are no longer medically necessary, the provider shall complete a discharge notice and deliver the notice to the resident or the resident's representative within five (5) working days from the date of the evaluation. A copy of the discharge notice shall be sent to the appropriate Medicaid Long Term Care Eligibility Unit staff on the same day it is given to the resident or the resident's representative.
- (ii) Medicaid reimbursement shall continue for services provided to the resident for up to thirty (30) days after the date of the delivery of the discharge notice.
(c) Re-evaluations of medical necessity for clients of LTC HCBS or ALF HCBS Waiver services or PACE services. - (i) When a re-evaluation of medical necessity indicates that LTC HCBS or ALF HCBS Waiver or PACE services are no longer medically necessary:
- (A) A notice of denial of service letter shall be given to the client by the medical necessity evaluator.
- (B) Upon notification of the adverse decision of the evaluation of medical necessity, the case manager shall complete a discharge notice (HCBS10) and deliver it to the client.
- (ii) Medicaid reimbursement shall continue for services provided to the client until the last day of the approved plan of care.
(d) Retroactive payments. Retroactive payments may be available pursuant to Chapter 19.
048-22 Wyo. Code R. § 22-5