048-30 Wyo. Code R. § 30-8

Current through April 27, 2019

Section 30-8 - Medicaid allowable payment for inpatient hospital services

(a) In General. Medicaid reimbursement for inpatient hospital services, other than specialty services and services paid a per diem as specified in this Chapter, is based on the level of care provided to each recipient. The payment rate is based on a hospital-specific rate or a level of care payment rate capped by the statewide ceiling as set forth in this Chapter, and payments shall not be cost settled based on actual costs.

(b) Levels of care. Inpatient hospital services are divided in the following levels of care:

(i) Maternity care - Surgical;

(ii) Maternity care - Medical;

(iii) Intensive care unit ("ICU")/Cardiaccare unit ("CCU") services/Burn Care;

(iv) Major surgery;

(v) Level of care psychiatric services;

(vi) Rehabilitation services;

(vii) Normal newborn care;

(viii) Newborn readmission care; and

(ix) Routine care.

(c) Payment rates for each level of care are determined pursuant to Sections 9 through 11, except that services which are or become specialty services are reimbursed pursuant to Chapter 31.

(d) Hierarchy of levels of care. Inpatient hospital services are reimbursed pursuant to the following hierarchy, unless otherwise reimbursed as specialty services.

(i) Specialty services;

(ii) Maternity care - Surgical;

(iii) Maternity care - Medical;

(iv) Intensive care unit (ICU)/Cardiac care unit (CCU) services/Burn Care;

(v) Major surgery;

(vi) Level of care psychiatric services;

(vii) Rehabilitation services;

(viii) Normal newborn;

(ix) Newborn readmission care; and

(x) Routine care.

(e) Services that require prior authorization or admission certification. The Division may, from time to time, designate covered services that require prior authorization or admission certification. In designating such services, the Division shall consider the cost of the service, the potential for over-utilization of the service, and the availability of lower cost alternatives. The Division shall disseminate a current list of services that require prior authorization or admission certification to providers through Provider Manuals or Provider Bulletins.

048-30 Wyo. Code R. § 30-8