048-3 Wyo. Code R. § 3-3
Except as otherwise specified in this section, the terminology used in this Chapter is the standard terminology and has the standard meaning used in health care, Medicaid and Medicare.
(a) "Business agent." A person or entity that submits a claim for or receives Medicaid funds on behalf of a provider.
(b) "Certified mail, return receipt requested." Certified mail, return receipt requested as provided by the United States Postal Service, or delivery via a commercial delivery service which provides tracking of the communication and written documentation of its delivery. "Certified mail, return receipt requested" does not include communication by facsimile transmission, telephone, or electronic mail.
(c) "Chapter 1." Chapter 1, Rules for Medicaid Administrative Fair Hearings, of the Wyoming Medicaid rules.
(d) "Chapter 2." Chapter 2, State Licensed Shelter Care Eligibility and Services, of the Wyoming Medicaid Rules.
(e) "Chapter 4." Chapter 4, Third Party Liability, of the Wyoming Medicaid rules.
(f) "Chapter 8." Chapter 8, Inpatient Hospital Certification, of the Wyoming Medicaid rules.
(g) "Chapter 16." Chapter 16, Medicaid Program Integrity, of the Wyoming Medicaid rules.
(h) "Chapter 35." Chapter 35, Medicaid Benefit Recovery, of the Wyoming Medicaid rules.
(i) "Chapter 38." Chapter 38, Safeguarding Information on Applicants and Recipients, of the Wyoming Medicaid rules.
(j) "Chapter 39." Chapter 3 9, Recovery of Excess Payments, of the Wyoming Medicaid rules.
(k) "Claim." A request by a provider for Medicaid payment for services provided to a recipient.
(l) "Covered service." Services which are reimbursable pursuant to the rules of the Division.
(m) "Department." The Wyoming Department of Health, its agent, designee, or successor.
(n) "Department of Family Services (DFS)." The Wyoming Department of Family Services, its agent, designee, or successor.
(o) "Division." The Division of Health Care Financing of the Department, its agent, designee, or successor.
(p) "Emergency." The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:
(q) "Enrolled." A provider that has signed a provider agreement and has been enrolled as a provider with the Division.
(r) "Equipment." Items, including durable medical equipment, that are designed for repeated use, have a medical purpose and are intended for home use.
(s) "Excess payments." "Excess payments" as defined in Chapter 39, which definition is incorporated by this reference.
(t) "Federal Medicaid Percentage (FMAP)." "Federal medical assistance percentage" as defined in 42 U.S.C. § 1396 d(b), which definition is incorporated by this reference.
(u) "Financial records." All records, in whatever form, used or maintained by a provider in the conduct of its business affairs and which are necessary to substantiate or understand claims submitted to the Department.
(v) "HCFA." The Health Care Financing Administration of the United States Department of Health and Human Services, its agent, designee, or successor.
(w) "Legally authorized representative." A minor child's parent or legal guardian; an individual's legal guardian; an attorney who asserts, in writing, that he or she represents an individual or entity; or any other person who is authorized in writing to act on behalf of an individual or entity. Any person, other than a parent acting on behalf of a minor child or an attorney who represents an individual or entity, must attach to the first document submitted to the Division a copy of a written authorization to act on behalf of the specified individual or entity with respect to the particular matter in question.
(x) "Local agency." The County office of DFS, its agent, designee, or successor.
(y) "Local trade area." The geographic area surrounding the recipient's residence, including portions of states other than Wyoming commonly used by other persons in the same area to obtain similar services.
(z) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act and/or the Wyoming Medical Assistance and Services Act of 1967, as amended. "Medicaid" includes any successor or replacement program enacted by Congress or the Wyoming Legislature.
(aa) "Medicaid allowable payment." The maximum Medicaid reimbursement as determined pursuant to the rules of the Department.
(bb) "Medicaid funds." That combination of Federal Medicaid funds and State Medicaid funds which is available to the Division to make payments to provider's. The federal portion shall be the FMAP. The state portion shall be the State Medicaid percentage.
(cc) "Medicaid Fraud Control Unit (MFCU)." The Medicaid Fraud Control Unit of the Wyoming Attorney General's Office, its agent, designee, or successor.
(dd) "Medically necessary or medical necessity." A health service that is required to diagnose, treat, cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected; to relieve pain; or to improve and preserve health and be essential to life. The service must be:
(ee) "Medical records." All records, in whatever form, in the possession of or subject to the control of a provider which describe the recipients diagnosis, treatment or condition.
(ff) "Medicare." The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.
(gg) "Minimum Medical Program (MMP)." The Minimum Medical Program as established by the MMP rule.
(hh) "MMP rule." Chapter 1, Minimum Medical Program, of the Departments rules.
(ii) "Overpayment." Overpayment as defined in Chapter 39, which definition is incorporated by this reference.
(jj) "Prior authorized." Approval by the Division pursuant to Section 9. "Prior authorized" does not include admission certification pursuant to Chapter 8.
(kk) "Provider." Any individual or entity that has a current provider agreement, is licensed and/ or certified to provide services, and is enrolled with the Division.
(ll) "Provider agreement." A written contract between a provider and the Division in which the provider agrees to comply with the provisions of the provider agreement as a condition of receiving Medicaid payment for services provided to recipients.
(mm) "Recipient." A person who has been determined eligible for Medicaid.
(nn) "Residence." The place a recipient uses as his or her primary dwelling place and intends to continue to use indefinitely for that purpose.
(oo) "Service." Health services, medical supplies or equipment provided to a recipient.
(pp) "Service area." The State of Wyoming and the following cities or towns: Craig, Colorado; Idaho Falls, Montpelier and Pocatello, Idaho; Billings and Bozeman, Montana; Kimball and Scottsbluff, Nebraska; Belle Fourche, Custer, Deadwood, Rapid City and Spearfish, South Dakota; and Ogden and Salt Lake City, Utah.
(qq) "Service limitations." Limits on the quantity of covered services which are Medicaid reimbursable as set forth in the rules of the Department.
(rr) "State licensed shelter care." The state licensed shelter care program as established by Chapter 2.
(ss) "State Medicaid percentage." The state percentage as determined pursuant to 42 U.S.C. § 1396 d(b).
(tt) "Third party payer." "Third party payer" as defined in Chapter 4, which definition is incorporated by this reference.
(uu) "Usual and customary charge." The provider's charge for comparable services provided to non-recipients.
048-3 Wyo. Code R. § 3-3