048-29 Wyo. Code R. § 29-4
(a) "Abuse." Abuse as defined in Chapter 16, Section 4(a), which is incorporated by this reference.
(b) "Administrator". The administrator of the division, the administrators agent, designee or successor.
(c) "Admission" or "admitted." "Admission" or "admitted" as defined by Chapter 30, which is incorporated by this reference.
(d) "Appropriate." Appropriate as defined by Chapter 8, which definition is incorporated by this reference.
(e) "Case management." Assistance to a recipient in gaining access to medically necessary care and services appropriate to the needs of the recipient through education, coordination of services, monitoring of services, or other appropriate means. Case management is provided by the Division.
(f) "Case management referral." A communication, written or oral, from the Department, a health care professional or any other source, to the Division, indicating the potential need for case management.
(g) "Case manager." A registered nurse or a health care professional designated by the Division to provide case management.
(h) "Chapter 1." Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid rules.
(i) "Chapter 3." Chapter 3, Provider Participation, of the Wyoming Medicaid rules.
(j) "Chapter 6." Chapter 6, Health Check Program, of the Wyoming Medicaid rules.
(k) "Chapter 8." Chapter 8, Inpatient Admission Certification, of the Wyoming Medicaid rules.
(l) "Chapter 16." Chapter 16, Medicaid Program Integrity, of the Wyoming Medicaid rules.
(m) "Chapter 28." Chapter 28, Swingbed Services, of the Wyoming Medicaid rules.
(n) "Chapter 30." Chapter 30, Level of Care Hospital Reimbursement, of the Wyoming Medic-aid rules.
(i) "Covered services." Health care services, medical supplies and equipment which are Medic-aid reimbursable pursuant to the rules of the Department.
(j) "Department." The Wyoming Department of Health, its agent, designee or successor.
(k) "Department of Family Services (DFS)." The Wyoming Department of Family Services, its agent, designee or successor.
(l) "Disabled adult." Disabled adult as defined in W.S. 35-20-102(a)(vi), which is incorporated by this reference.
(m) "Discharge." The act by which an individual that has been admitted to a hospital as an inpatient is released from the hospital. Discharge does not include an individual that is transferred from one unit of a hospital to another unit in the hospital, an individual that is transferred to a distinct part hospital unit, or an individual that is transferred to another hospital.
(n) "Division." The Division of Health Care Financing of the Department, it agent, designee or successor.
(o) "DSM." The most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, which is incorporated by this reference. The DSM is published by the American Psychiatric Association, Washington, D.C., and is available from the publisher.
(p) "EPSDT." EPSDT as defined in Chapter 6, which is incorporated by this reference.
(q) "Excess payments." Medicaid funds received by a provider which exceed the Medicaid allowable payment established by the Department. Excess payments includes a reduction in the Medicaid allowable payment pursuant to Section 5.
(r) "Expanded EPSDT services." Expanded EPSDT services as defined in Chapter 6, which is incorporated by this reference.
(s) "Extended psychiatric care." "Extended psychiatric care as defined in Chapter 30, which is incorporated by this reference.
(t) "Extended stay report." A report which contains information about recipients that have been inpatients for five days or more. A extended stay report shall be in writing, and shall contain the information and be in the form specified by the Department.
(u) "Extraordinary recipients." Extraordinary recipients as defined by Chapter 28, which definition is incorporated by this reference.
(v) "Facility." A hospital, nursing facility. psychiatric hospital or rehabilitation facility.
(w) "HCFA." The Health Care Financing Administration of HHS.
(x) "Health care professional." An individual licensed under the laws of Wyoming or another state to practice medicine, osteopathy, dentistry, nursing or any other professional health care, acting within the scope of his or her licensure.
(y) "Heavy care patient." Heavy care patient as defined by Chapter 28, which definition is incorporated by this reference.
(z) "HHS." The United States Department of Health and Human Services, including the Office of Inspector General.
(aa) "High cost services." Covered services furnished to or expected to be furnished to a recipient admitted to a facility with a severe medical problem, or a recipient that receives noninstitutional services for a severe medical problem. High cost services includes, but is not limited to:
(bb) "Hospital." An institution that:
(cc) "Inappropriate utilization of covered services". A recipients receipt of covered services which are not medically necessary or appropriate, or which are furnished in a setting which is not appropriate.
(dd) "Inpatient." An "inpatient" as defined by 42 C.F.R. 440.2(a), which is incorporated by this reference.
(ee) "Inpatient Census Report (ICR)." A report which contains information about recipients admitted as inpatients to a hospital. An ICR shall be in writing, and shall contain the information and be in the form specified by the Division.
(ff) "Inpatient hospital services." Inpatient hospital services as defined in 42 C.F.R. 440.10, which is incorporated by this reference.
(gg) "Lock-in." Restricting a recipients participation in Medicaid to receiving covered services from a provider or providers designated by the recipient and approved by the Division.
(hh) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services act of 1 9 67, as amended.
(ii) "Medicaid allowable payment." Payment for covered services as permitted by the Medicaid rules and policies of the Department.
(jj) "Medical necessity criteria." The medical necessity criteria established pursuant to Chapter 8, which are incorporated by this reference.
(kk) "Medical record." All documents, in whatever form, in the possession of or subject to the control of the provider which describe the recipients diagnosis, condition or treatment.
(ll) "Medically necessary" or "medical necessity." A covered service that is:
(mm) "Medicare." The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.
(nn) "Monitor." To track a recipients utilization of covered services by any or all of the following methods:
(oo) "Neglected child." "Neglected child" as defined by W.S. W.S. W.S. 14-6-201(a)(xvi), which is incorporated by this reference.
(pp) "NICU Level III." NICU Level III as defined by Chapter 8, which definition is incorporated by this reference.
(qq) "Nursing facility." Nursing facility as defined by 42 U.S.C. 1396 d(f), which is incorporated by this reference.
(rr) "Nursing facility services." Nursing facility services as defined by 42 U.S.C. 1396 d(f), which is incorporated by this reference.
(ss) "Physician." A person licensed to practice medicine or osteopathy by the Wyoming Board of Medical Examiners or a comparable agency in another state, or a person licensed to practice dentistry by the Wyoming Board of Dental Examiners or a comparable agency in another state.
(tt) "Prior authorized." Approval by the Division pursuant to Chapter 3, Section 9, which is incorporated by this reference.
(uu) "Provider." A provider as defined by Chapter 3, which definition is incorporated by this reference.
(vv) "Psychiatric diagnosis." A condition defined in the DSM, excluding a sole diagnosis of mental retardation or a specific developmental disorder.
(ww) "Psychiatric services." Psychiatric services as defined by Chapter 30, which definition is incorporated by this reference.
(xx) "Recipient." A person who has been determined eligible for Medicaid.
(yy) "Registered nurse." A person licensed to practice professional nursing by the Wyoming Board of Nursing or a similar agency in another state.
(zz) "Rehabilitation services." Rehabilitation services as defined by Chapter 30, which definition is incorporated by this reference.
(aaa) "Services." Health care services or supplies furnished to a recipient.
(bbb) "Severe medical problem." An injury or illness which results in cognitive or physical debilitation requiring intensive and/or expensive services, as determined by the Division. Severe medical problem includes, but is not limited to:
(ccc) "Specialty services." Specialty services as defined by Chapter 30, which definition is incorporated by this reference.
(ddd) "Transplants." Transplants as defined by Chapter 30, which definition is incorporated by this reference.
(eee) "Traumatic brain injury (TBI)." An acquired assault to the brain.
(fff) " Working day." 8:00 a.m. through 5:00 p.m., Mountain Time, Monday through Friday, exclusive of State holidays.
048-29 Wyo. Code R. § 29-4