Section 29-6 - Case management (a) Applicability. - (i) Existing recipients.
- (A) The Department and health care professionals are authorized to identify recipients that appear to require assistance in using covered services appropriately because of unfamiliarity with the Medicaid program or the delivery of services, or for any other reason; or
- (B) If the Department learns that a recipient with a severe medical problem is receiving covered services, or that a recipient is receiving high cost services, the Department may monitor the services provided to that recipient.
- (ii) New recipients. The Department may request that new recipients participate in case management for the reasons set forth in (i) or for any other reason.
(b) Procedure. After a recipient is identified pursuant to subsection (a), the Department shall: - (i) Notify the recipient pursuant to Section 10 that the recipient has been selected to participate in case management, and that the recipient has the option of participating. If the respondent does not respond to the notice within the time specified in the notice, the recipient shall be deemed to have agreed to case management services.
- (ii) Refusal to participate. The refusal by a recipient to participate in case management shall not restrict the Medicaid services otherwise available to the recipient. A recipients refusal to participate shall not restrict the Divisions ability to perform case management provided there is no reduction in the services provided to the recipient.
(c) Methods of case management. After the Department identifies a recipient pursuant to (a), it may: - (i) Monitor the recipients utilization of covered services to ensure that it is medically necessary;
- (ii) Facilitate and coordinate placement in a more appropriate setting to ensure that the recipient receives appropriate services in the most efficient manner and/or setting consistent with appropriate care for the recipients condition;
- (iii) Conduct concurrent reviews pursuant to Chapter 8;
- (iv) Conduct periodic utilization reviews to determine whether the recipient is engaged in a pattern of inappropriate utilization of covered services;
- (v) Conduct on-site reviews to determine whether the services being furnished are medically necessary and appropriate; or
- (vi) Take any other appropriate measures to coordinate and facilitate the provision of covered services in the most efficient manner and/or setting consistent with appropriate care for the recipients condition.
048-29 Wyo. Code R. § 29-6