048-3 Wyo. Code R. § 3-11

Current through April 27, 2019

Section 3-11 - Payment and submission of claims

(a) Payer of last resort. Medicaid is the payer of last resort. A provider may not seek Medicaid payment for services furnished to a recipient until payment from third parties has been sought pursuant to Chapter 4 and/or Chapter 35.

(b) Payment in full of covered services. If the service is a covered service, a provider may not request, receive or attempt to collect any payment from the recipient or the recipient's family for the service. The provider must accept the Medicaid allowable payment as payment in full for the services. This subsection does not apply to services provided in excess of service limitations.

(c) Payment for noncovered services. A provider that provides a noncovered service to a recipient may seek payment from the recipient if the provider informed the recipient, in writing, of the recipient's potential liability before providing the service, and the recipient agreed in writing to pay for such services before they were furnished.

(d) Payment for services that exceed service limits. A provider that provides a covered service to a recipient that is in excess of service limits may seek payment from the recipient without complying with subsection (c).

(e) Copayment. A provider may seek copayment from recipients as permitted by the rules of the Department. The amount of the authorized copayment shall be automatically deducted by the Division from the Medicaid allowable payment. Collection of copayment is the sole responsibility of the provider.

(f) Submission of claims.

• (i) Claims must be submitted to the Division in the manner and on the forms specified by the Division, must include documentation of prior authorization, if necessary, and such other documentation or records as the Division may request.

• (ii) Except as specified below, claims must be submitted to and finalized on or before twelve months after the date of service or the date of discharge, whichever is later.
  • (A) Medicare cross-over claims must be submitted within six months after the date Medicare acts on the claim; and
  • (B) In the event of retroactive eligibility, claims must be submitted within six months of the date of the determination of retroactive eligibility.
  • (C) The date of submission is the date the claim is received by the Division.
  • (D) Claims not timely submitted shall be rejected.

• (iii) A provider shall not bill the Division in excess of the provider's usual and customary charge for the service.

• (iv) A provider may seek Medicaid payment through a business agent for services furnished to a recipient if the business agent's compensation is related to the actual cost of processing the billing and is not related on a percentage or other basis to the amount of the claim and is not dependent upon payment of the claim.

• (v) A provider is responsible for all claims, whether submitted directly or through an agent, designee, employee or other intermediary.

• (vi) Any loss of Medicaid reimbursement caused by provider error is the responsibility of the provider and the provider may not bill the recipient for such services.

048-3 Wyo. Code R. § 3-11