(a) Verify and obtain information. At the time a client requests services from a provider, the provider shall review the client's eligibility card for information regarding third party payers. The provider shall ask the client if the information on the card is current and whether there are or may be additional third party payers. If the provider learns of a potential third party payer that is not listed on the eligibility card, the provider shall notify the Department in writing of that information within thirty (30) calendar days.
(b) Notify the Department of requests for information. Release of information by providers for casualty related third party resources not known to the State may be identified through requests for medical reports and bills received by providers from attorneys, insurance companies, and other parties. Providers shall contact the Department before responding to such requests.
(c) Notification of death. - (i) An institutional provider shall notify the Department, in writing, of any client's death which occurs in the facility or which occurs after the client is transported from the provider's facility to another facility, such as a hospital or hospice.
- (ii) Time of notice. The notification shall be sent to the Department on or before the end of the third working day after the client's death.
- (iii) Contents of notice. The notification shall be in the form and contain the information required by the Department, as specified in the Provider Manual.
(d) Billing. Unless otherwise provided by a TPL waiver, this subsection shall govern the submission of bills involving third party payers. - (i) When a provider is informed that the client has or may have coverage by a third party payer, the provider shall seek payment from the third party payer prior to submitting a Medicaid claim. When the amount payable by the third party payer is less than the allowable Medicaid payment, the provider may submit a Medicaid claim for the difference. The Medicaid claim shall be accompanied by documentation of the amount payable by the third party payer or submitted electronically with the appropriate coordination of benefits information, including claims adjustment reason and remark codes.
- (ii) If a third party payer rejects the request for payment, the provider may submit a Medicaid claim to the Department. The provider shall attach a copy of the notice of rejection to the Medicaid claim, upload a copy of the notice of rejection to the Medicaid web portal to be linked to the corresponding electronic claim, or submit the Medicaid claim electronically with the appropriate coordination of benefits information, including claims adjustment reason and remark codes.
- (iii) If a provider has not received payment or a rejection notice from a third party payer within ninety (90) days after submitting two (2) requests or attempts for payment, the provider may submit a Medicaid claim. The provider shall submit with the Medicaid claim, copies of the requests for payment to the third party payer, and any written communication the provider has received from the third party payer.
- (iv) A provider which has received payment from a third party payer may submit a Medicaid claim. In such cases the provider shall submit with the Medicaid claim documentation of the payment received. The Department shall allow the Medicaid claim only to the extent the allowable Medicaid reimbursement exceeds the payment received from the third party payer and subject to the Department's normal procedures and standards.
- (v) A provider shall submit Medicaid claims to the Department within twelve (12) months of the date of service or discharge, whichever is later, regardless of the potential involvement of a third party payer, except that Medicare crossover claims shall be submitted within six (6) months after the date of payment or rejection by Medicare. Medicaid claims submitted after the time limits specified in this paragraph shall be rejected. Refer to Chapter 3 of the Medicaid rules for further information.
- (vi) For the purposes of paragraph (d)(i) of this section, any amount paid by Medicaid when combined with the amount paid by the third party payer, shall not exceed the amount payable to the provider under any preferred provider or similar agreement between the provider and that third party payer. The Department is only responsible for the patient's responsibility.
- (vii) A provider shall not opt-out of participation with a third party payer. If a provider chooses to opt-out of participation with a third party payer, the Department shall not pay for services covered by, but not billed to, the third party payer. The provider shall work with the third party payer or client to have the claim submitted to the carrier.
- (viii) If a provider chooses to bill Wyoming Medicaid, the provider accepts Medicaid payment as payment in full. The provider shall not bill Wyoming Medicaid and accept payment and bill the other third party. The provider shall choose whether to bill Wyoming Medicaid or bill the other party and wait for legal liability to be established.
048-35 Wyo. Code R. § 35-7