(a) Procedures. A provider seeking reimbursement for services which require prior authorization shall request prior authorization pursuant to the procedures and in the format specified by the Department and disseminated to providers through manuals or bulletins. - (i) Criteria for review. Prior authorization shall be granted if the proposed services:
- (A) Are covered services;
- (B) Are consistent with the client's diagnosis;
- (C) Are medically necessary;
- (E) Meet the criteria established by the rules of the Department; and
- (F) Are not reimbursable by any third party payer.
- (ii) Denial of prior authorization. The Department shall provide written notice of the denial of prior authorization to the provider and the client.
- (A) If a request for prior authorization is denied, the provider may submit a revised request for prior authorization or additional documentation, as necessary, for the Department to reconsider the matter; or
- (B) The provider or client may request reconsideration of the denial of prior authorization pursuant to Chapter 4 of the Wyoming Medicaid Rules. If a timely request for reconsideration is made, the services shall be furnished for up to sixty (60) days while the Department reconsiders the denial. The Department shall provide a written notice of its decision on reconsideration.
- (C) The denial of prior authorization precludes Medicaid reimbursement for the services in question, except to the extent services are furnished pending reconsideration pursuant to subsection (B).
- (iii) Failure to timely request prior authorization. The failure to obtain prior authorization before providing services requiring authorization precludes Medicaid reimbursement for such services.
- (iv) Effect of prior authorization. Granting prior authorization shall constitute approval for the provider to receive Medicaid reimbursement for the approved services to be furnished, subject to the other requirements of this and the other Medicaid rules of the Department and post payment review. Prior authorization is not a guarantee of the client's eligibility or a guarantee of Medicaid payment.
(b) Services that require prior authorization. - (i) This and other rules of the Department specify services that require prior authorization. Notice of services requiring prior authorization can be found in manuals, bulletins, faxes, and designated websites published by the Department.
- (ii) Designation of additional services. The Department may designate additional services that require prior authorization pursuant to this paragraph.
- (A) Request for designation. The Department, the P&T Committee, a provider, a client, an organization of providers or clients, or any other person, may request that the Department consider designating a service as requiring prior authorization. Except when requested by the Department, such a request shall be delivered to the Department in the form and manner specified by the Department.
- (B) Referral to the P&T Committee. Any request for designation received by or made by the Department shall be referred to the P&T Committee.
- (C) Review by P&T Committee. The P&T Committee may review a referral received from the Department to designate a service as requiring prior authorization. In reviewing any such referral, the P&T Committee may consider the:
- (I) Clinical efficacy of the service as demonstrated by:
- (1) peer-reviewed clinical literature;
- (2) nationally recognized practice standards; and
- (3) the consensus of the members of the P&T Committee;
- (II) Cost effectiveness of the service;
- (III) Potential for over-utilization of the services;
- (IV) The availability of lower cost alternatives; and
- (V) Comments received from interested parties for services which are under consideration for designation as requiring prior authorization.
- (D) Recommendation to the Department. The P&T Committee shall make a recommendation to the Department about whether it should designate a service as requiring prior authorization. Such recommendation shall include the criteria to be used in determining whether to prescribe such services.
- (E) Consideration of recommendation. The Department may consider the recommendation of the P&T Committee in determining whether to designate services as requiring prior authorization. The Department may also consider information from CMS and other sources of clinical information which it deems relevant to the determination. The Department shall not be bound by the recommendation of the P&T Committee, but the Department shall not designate a service as requiring prior authorization until it has received the P&T Committee's recommendation.
- (iii) Notice of services which require prior authorization.
- (A) The Department shall, from time to time, disseminate a current list of services which require prior authorization to providers through manuals, bulletins, facsimiles, designated websites, or other appropriate means.
- (B) If additional services are designated pursuant to this section, the Department shall disseminate notice of the additional services which require prior authorization to providers through manuals, bulletins, facsimiles, designated websites, or other appropriate means.
048-10 Wyo. Code R. § 10-13