048-30 Wyo. Code R. § 30-4

Current through April 27, 2019

Section 30-4 - Definitions

(a) "Active treatment." Active treatment as set forth in 42 C.F.R. § 441.154, which is incorporated by this reference.

(b) "Acute." Having a short and relatively severe course.

(c) "Acute stabilization." The process of bringing to stability an acute medical or psychological condition within a relatively short time through the administration of inpatient hospital services.

(d) "Admission" or "admitted." The act that allows an individual to officially enter a hospital to receive inpatient hospital services under the supervision of a physician who is a member of the hospitals medical staff. "Admission" or "admitted" does not include an individual that is transferred from one unit of a hospital to another unit in the hospital or to a distinct part hospital unit.

(e) "Admission certification." Admission certification as defined by Chapter 8, which is incorporated by this reference.

(f) "Allowable costs." Medicare allowable costs as determined by 42 U.S.C. § 1395(f), except as otherwise specified by this Chapter.

(g) "Attending physician." The physician of record during a recipients hospitalization for acute stabilization.

(h) "Ancillary services charges." Charges for furnishing inpatient ancillary services to a patient reported on a claim.

(i) "Average length of stay." The average length of stay is calculated by the Department and is equal to the average number of days a recipient remains in a hospital as an inpatient during the base period. The average length of stay is the sum of all lengths of stay divided by the number of claims. The length of stay is the number of inpatient days reported on a claim, excluding the date of discharge.

(j) "Base period." With respect to operating costs, a hospitals most recently audited twelve month cost reporting period which ends on or before August 31, 1994. With respect to claims and discharge data, the period from July 1, 1994 through December 31, 1996. With respect to capital costs, the most recently settled cost report year as of October 15, 1993.

(k) "CARF." The Commission on Accreditation of Rehabilitation Facilities.

(l) "Capital costs." Capital related costs as defined in 42 C.F.R. § 413.130, which is incorporated by this reference.

(m) "Certified." Approved by the survey agency as in compliance with applicable statutes and rules.

(n) "Chapter 1." Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid rules.

(o) "Chapter 3." Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.

(p) "Chapter 4." Chapter 4, Third Party Liability, of the Wyoming Medicaid Rules.

(q) "Chapter 8." Chapter 8, Inpatient Admission Certification, of the Wyoming Medicaid Rules.

(r) "Chapter 9." Chapter 9, Hospital Services, of the Wyoming Medicaid Rules.

(s) "Chapter 16." Chapter 16, Medicaid Program Integrity, of the Wyoming Medicaid Rules.

(t) "Chapter 24." Chapter 24, Wyoming Hospital Reimbursement System, of the Wyoming Medicaid Rules.

(u) "Chapter 28." Chapter 28, Swingbed Services, of the Wyoming Medicaid Rules.

(v) "Chapter 31." Chapter 31, Selective Contracting of Inpatient Hospital Services, of the Wyoming Medicaid Rules.

(w) "Chapter 32." Chapter 32, Disproportionate Share Hospital Reimbursement, of the Wyoming Medicaid Rules.

(x) "Chapter 37." Chapter 37, Fiscal Responsibility, of the Wyoming Medicaid Rules.

(y) "Chapter 39." Chapter 39, Recovery of Excess Payments, of the Wyoming Medicaid Rules.

(z) "Childrens hospital." An inpatient hospital which is:

(i) Designated by the Secretary of HHS as a childrens specialty hospital;

(ii) Exempt from the Medicare PPS; and

(iii) Is a participating provider.

(aa) "Claim." A request by a provider for Medicaid payment for covered services provided to a recipient.

(bb) "Cost report." A cost report prepared and submitted in conformance with Medicare requirements. "Cost report" includes any supplemental request by the Department for additional information relating to the hospitals costs.

(cc) "Covered service." A health service or supply eligible for Medicaid reimbursement pursuant to the rules of the Department. "Covered service" does not include nursing facility services provided in a swingbed.

(dd) "Department." The Wyoming Department of Health, its agent, designee or successor.

(ee) "Desk review." A review by the Department of a hospitals cost report to determine:

(i) if the cost report has been prepared and submitted in compliance with this Chapter;

(ii) that costs have been properly allocated; and

(iii) that costs are allowable.

(ff) "Diagnosis codes." Diagnosis codes as contained in the International Classification of Diseases, 9th Revision, Clinical Modification ("ICD-9-CM"), which is incorporated by this reference. The ICD-9-CM is authorized by HCFA and is available from the United States Government Printing Office, Washington, D.C. 20402.

(gg) "Direct medical education." Direct medical education as defined by 42 C.F.R. § 413.86(a)(2), which is incorporated by this reference.

(hh) "Director." The Director of the Department or the Directors designee.

(ii) "Discharge." The act by which an individual that has been admitted to a hospital as an inpatient is released from the hospital. "Discharge" does not include an individual that is transferred from one unit of a hospital to another unit in the hospital, an individual that is transferred to a distinct part hospital unit, or an individual that is transferred to another hospital.

(jj) "Discharge planning." To make arrangements during a recipients hospitalization for the recipient to receive appropriate services at such time that inpatient hospital services will no longer be medically necessary.

(kk) "Disproportionate share hospital." A disproportionate share hospital as defined by Chapter 32, which is incorporated by this reference.

(ll) "Distinct part hospital unit." A distinct part hospital unit excluded from the Medicare prospective payment system pursuant to 42 C.F.R. § 412.20(b)(1), which is incorporated by this reference.

(mm) "Division." The Division of Health Care Financing of the Department, its agent, designee or successor.

(nn) "Enrolled." Enrolled as defined in Chapter 3, Section 3(l), which is incorporated by this reference.

(oo) "Excess payments." Excess payments as defined in Chapter 39, which definition is incorporated by this reference.

(pp) "Extended psychiatric care." Inpatient psychiatric services, other than level of care psychiatric services, provided to a recipient under age twenty-one if:

(i) Ambulatory care services in the recipients community of residence do not meet the recipients treatment needs and inpatient treatment is medically necessary;

(ii) Services are provided in a psychiatric hospital, a distinct part hospital unit or a residential treatment center;

(iii) The recipient is referred for extended psychiatric care by the attending physician;

(iv) Services are provided under the direction of a physician and involve active treatment that is reasonably expected to improve the recipients condition or prevent further regression of the recipients condition so that such services will no longer be necessary; and

(v) Services are medically necessary.

(vi) Maintenance psychiatric services are reimbursable only if:
- (A) There is a downward change in the acuity level of patient treatment; or
- (B) The recipient is ready for discharge and community care resources are not available to furnish appropriate follow-up care.

(vii) Services provided to a recipient that is not under age twenty-one are reimbursable only if the recipient was receiving services in the period immediately preceding the date on which the recipient attains age twenty-one. Such services are reimbursable until the earlier of:
- (A) The date services are no longer medically necessary; or
- (B) The month in which the recipient attains age twenty-two.

(viii) The service is not acute stabilization.

(qq) "Extraordinary circumstances." A catastrophic occurrence, beyond the control of a provider, which results in substantially higher costs and which meets the criteria of (i) through (v). "Extraordinary circumstances" include, but are not limited to, fire, earthquakes, floods or other natural disasters, and which:

(i) Is a one-time occurrence;

(ii) Could not have reasonably been predicted;

(iii) Is not insurable;

(iv) Is not covered by federal or state disaster relief; and

(v) Is not the result of intentional, reckless or negligent actions or inactions by any director, officer, employee or agent of the provider.

(rr) "Field audit." An examination, verification and review of a providers financial records and any supporting or related documentation conducted by employees, agents or representatives of the Department or HHS. A field audit may be conducted at the hospital.

(ss) "Financial records." All records, in whatever form, used or maintained by a hospital in the conduct of its business affairs and which are necessary to substantiate or understand the information contained in the hospitals cost reports or a claim.

(tt) "Generally accepted auditing standards (GAAS)." Auditing standards, practices and procedures established by the American Institute of Certified Public Accountants.

(uu) "Geometric mean length of stay." The exponential value of the average (mean logarathim) value of all natural logarathims of all lengths of stay.

(vv) "HCFA." The Health Care Financing Administration of the United States Department of Health and Human Services, its agent, designee or successor.

(ww) "HCPCS." The HCFA common procedures coding system.

(xx) "HHS." The United States Department of Health and Human Services, its agent, designee or successor.

(yy) "Hospital." An institution that:

(i) is approved to participate as a hospital under Medicare;

(ii) is maintained primarily for the treatment and care of patients with disorders other than mental diseases or tuberculosis;

(iii) has a provider agreement;

(iv) is enrolled in the Medicaid program; and

(v) is licensed to operate as a hospital by the State of Wyoming or, if the institution is out-of-state, licensed by the state in which the institution is located.

(zz) "Hospital specific payment rate." A level of care payment rate based on a participating providers allowable costs and calculated pursuant to Section 10.

(aaa) "Incentive payment." An additional payment to a hospital for a level of care capped by the statewide ceiling when the hospital's mean cost per discharge for that level of care is less than the statewide mean cost per discharge for that level of care. An incentive payment is determined by subtracting the hospitals mean cost per discharge for the level of care from the statewide mean cost per discharge for that level of care, and multiplying the difference by twenty-five percent.

(bbb) "Inflation factor." The HCFA-PPS Hospital Market Basket index as published by DRI Data Resources Inc., in Health Care Costs, which is published quarterly by the DRI/McGraw division of McGraw-Hill, Inc. It is available from the publisher at 1200 G. Street, N.W., Washington, D.C. 20005. The inflation factors for historical data are from the Third Quarter 1996 historical tables for PPS type hospitals. The inflation factors for current data are from the Third Quarter 1996 historical tables for PPS type hospitals. The inflation factors for future years will be calculated using the Third Quarter National Forecasts for PPS Type Hospital Market Basket tables for the appropriate year.

(ccc) "Inpatient." An inpatient as defined by 42 C.F.R. § 440.2(a), which is incorporated by this reference.

(ddd) "Inpatient hospital service." Inpatient hospital services as defined by 42 C.F.R. § 440.10, which is incorporated by this reference.

(eee) "Intensive care unit (ICU)/critical care unit (CCU) services/Burn care." Inpatient hospital services which are:

(i) Provided to a patient who requires more intensive services than are furnished in a hospital's general medical or surgical unit;

(ii) Expected to require significant time to complete; and

(iii) Accompanied by a high risk of complications.

(iv) The Division shall, from time to time, designate services as ICU/CCU/Burn care based on diagnosis codes, revenue codes, and clinical consultation with health care professionals. The Division shall disseminate a current list of procedures designated as ICU/ CCU/Burn care to providers through Provider Manuals or Provider Bulletins.

(fff) "JCAHO." The Joint Commission on Accreditation of Healthcare Organizations.

(ggg) "Less than one day stay." An admission and discharge which occur within twenty-four hours.

(hhh) "Level of care." A measure of the intensity of services provided to inpatients. Inpatient hospital services are separated into levels of care as specified in Section 8. Medicaid payment for inpatient hospital services is based on the level of care provided to each discharge.

(iii) "Levels of care capped by the statewide ceiling." The following levels of care:

(i) Maternity care - Surgical;

(ii) Maternity care - Medical;

(iii) Normal newborn;

(iv) Newborn readmission care; and

(v) Routine.

(jjj) "Level of care payment rate." The payment rate for each level of care as determined pursuant to this Chapter.

(kkk) "Level of care psychiatric services." Acute stabilization services furnished to an individual with a psychiatric diagnosis. The Division shall, from time to time, designate psychiatric services as acute stabilization services based on diagnosis codes, clinical consultation with mental health professionals and HCFA guidelines. The Division shall disseminate a current list of acute stabilization services which are Medicaid reimbursable to providers through Provider Manuals or Provider Bulletins. Except for extended psychiatric care, Medicaid reimbursement is limited to acute stabilization.

(lll) "Maintenance psychiatric services." Covered extended psychiatric services identified by revenue code 680.

(mmm) "Major surgery." Surgical procedures that are mainly performed in a hospital operating room, are expected to require significant time to complete, and which carry an increased risk of complications. The Division shall, from time to time, designate surgical procedures as major surgery based on diagnosis codes, clinical consultation with health care professionals and HCFA guidelines. The Division shall disseminate a current list of major surgeries to providers through Provider Manuals or Provider Bulletins.

(nnn) "Maternity care - Medical." Routine prenatal services furnished to a pregnant mother, other than major surgery. The Division shall, from time to time, designate services as maternity care -medical based on diagnosis codes, clinical consultation with health care professionals and HCFA guidelines. The Division shall disseminate a current list of maternity care - medical services to providers through Provider Manuals or Provider Bulletins

(ooo) "Maternity care - Surgical." Prenatal services furnished to a pregnant mother which involve major surgery. The Division shall, from time to time, designate services as maternity care - surgical based on diagnosis codes, clinical consultation with health care professionals and HCFA guidelines. The Division shall disseminate a current list of maternity care - surgical services to providers through Provider Manuals or Provider Bulletins.

(ppp) "Medicaid." Medical assistance and services provided pursuant to Title XIX of the Social Security Act and/or the Wyoming Medical Assistance and Services Act. Medicaid includes any successor or replacement program enacted by Congress and/or the Wyoming Legislature.

(qqq) "Medicaid allowable costs." Medicaid program costs as determined from Medicare cost reports that have been submitted to and audited by the Medicare Fiscal Intermediary. Medicaid allowable costs and calculations of payments shall not be adjusted because of changes that result from a Medicare appeal or reopening.

(rrr) "Medically necessary" or "medical necessity." Medically necessary as defined by Chapter 8, which definition is incorporated by this reference.

(sss) "Medical record." All documents, in whatever form, in the possession of or subject to the control of the hospital which describe the recipients diagnosis, condition or treatment, including, but not limited to, the plan of care for the recipient.

(ttt) 'Medicare." The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.

(uuu) "Merged hospital." The surviving hospital in a merger or consolidation of two or more hospitals. A merged hospital includes the purchase of substantially all the assets of one or more hospitals by another hospital, in which each of the merged hospitals continues to operate as a hospital or part of a hospital.

(vvv) "Minor surgery." Surgical procedures that may be performed in a physicians office, which are expected to require minimal time for completion, or which carry a minimal risk of complications. The Division shall, from time to time, designate surgical procedures as minor surgery based on diagnosis codes, clinical consultation with health care professionals and HCFA guidelines. The Division shall disseminate a current list of minor surgeries to providers through Provider Manuals or Provider Bulletins.

(www) "Most recently settled cost report." A facility's most recent Medicare cost report which has been:

(i) submitted to Medicare in accordance with Medicare standards and procedures; and

(ii) cost settled by the Medicare intermediary using Medicare principles of cost reimbursement.

(xxx) "Newborn readmission care." Services provided to a recipient who is less than twenty-nine (29) days old, and who has been discharged and readmitted to a hospital. The Division shall, from time to time, designate services as newborn readmission care based on diagnosis codes, clinical consultation with health care professionals and HCFA guidelines. The Division shall disseminate a current list of newborn readmission care to providers through Provider Manuals or Provider Bulletins

(yyy) "New hospital." A hospital which was not a participating provider, or a hospital which was not enrolled before July 1, 1996. "New hospital" does not include a merged hospital.

(zzz) "Nonallowable costs." Costs which are not related to covered services, including costs specified in this Chapter and the other rules of the Department.

(aaaa) "Normal newborn care." Services furnished to a newborn, other than newborn readmission care. The Division shall, from time to time, designate normal newborn care services based on diagnosis codes, clinical consultation with health care professionals and HCFA guidelines. The Division shall disseminate a current list of normal newborn care services to providers through Provider Manuals or Provider Bulletins.

(bbbb) "Nursing facility services." Nursing facility services as defined in 42 U.S.C. § 1396 d(f), which is incorporated by this reference.

(cccc) "Obligated capital." Obligated capital as defined by Medicare.

(dddd) "Old capital." Capital for assets that were placed in use for patient care on or before December 31, 1990.

(eeee) "Outlier." With respect to determining outlier payments pursuant to Section 16, a discharge with allowable costs that exceed the outlier threshold. With respect to calculating the mean cost per discharge for each level of care, claims with allowable costs greater than two standard deviations above the mean cost per discharge for any given level of care.

(ffff) "Outlier threshold."

(i) Participating providers other than children's hospitals. Three times the hospitals level of care payment rate for each level of care.

(ii) Children's hospitals. Two times the hospital's level of care payment rate for each hospital-specific level of care for children's hospitals during the appropriate rate period.

(iii) An outlier threshold shall be determined and applied separately for each level of care. To determine if a claim exceeds that threshold, allowable costs are calculated as the hospital specific cost-to-charge ratio for each level of care, multiplied by the allowable charges submitted on the claim for that level of care. Facilities with cost-to-charge ratios greater than 1.0 shall be capped at the statewide cost-to-charge ratio for each level of care.

(gggg) "Overpayments." "Overpayments" as defined in Chapter 3 9, which definition is incorporated by this reference.

(hhhh) "Participating providers." All hospitals within Wyoming that are providers, and all out-of-state hospitals that were paid $250,000.00 or more by the Wyoming Medicaid program during the period from July 1, 1994, through December 31, 1996. Participating providers include all rehabilitation facilities and psychiatric hospitals that received Wyoming Medicaid funds during the period from July 1, 1994, through December 31, 1996.

(iiii) "Patient." An individual admitted to a hospital or other provider of inpatient hospital services.

(jjjj) "Physician." A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a comparable agency in another state, or a person licensed to practice dentistry by the Wyoming Board of Dental Examiners or a comparable agency in another state.

(kkkk) "PPS." The Medicare prospective payment system.

(llll) "Principal diagnosis." Principal diagnosis as defined by 42 C.F.R. § 412.60(c)(1), which is incorporated by this reference.

(mmmm) "Prior authorized." Approval by the Division pursuant to Chapter 3, Section 9, which is incorporated by this reference.

(nnnn) "Provider." A provider as defined by Chapter 3, Section 3(y), which is incorporated by this reference.

(oooo) "Psychiatric hospital." An institution that is accredited as a psychiatric hospital by the JCAHO.

(pppp) "Rate year." The State fiscal year (July 1 through the following June 30).

(qqqq) "Readmission." The act by which an individual is:

(i) Admitted to a provider from which the individual had been discharged;

(ii) On or before the thirty-first day after the previous discharge; and

(iii) For treatment of any diagnosis.

(iv) Newborn readmissions which occur within twenty-eight days after the newborns initial discharge are not readmissions.

(rrrr) "Rebase." To redetermine level of care payments using a base period which occurs after the base period as defined in this Chapter.

(ssss) "Recipient." A person who has been determined eligible for Medicaid.

(tttt) "Recipient under age twenty-one." A recipient before or during the month in which he or she turns twenty-one years of age.

(uuuu) "Rehabilitation services." Covered services identified by diagnosis codes V5700-V5799, unless such services are reimbursed as specialty services. The Division may, from time to time, designate rehabilitation services to be reimbursed as specialty services. In such event, the Division shall disseminate to providers, through Provider Manuals or Provider Bulletins, a current list of which rehabilitation services are reimbursed as specialty services and which are reimbursed pursuant to this Chapter.

(vvvv) "Rehabilitation facility." A free-standing rehabilitation treatment facility accredited by the JCAHO and operated primarily for the purposes of furnishing rehabilitative services.

(wwww) "Reopen." A request by a hospital, pursuant to the procedures and standards established by Medicare, to re-examine or review the correctness of a cost settlement determination or decision made by or on behalf of Medicare.

(xxxx) Residential treatment center (RTC). A facility or program accredited by the JCAHO, and operated for the primary purpose of providing residential psychiatric care to persons under age twenty-one, except as otherwise specified in this Chapter. The only services provided in an RTC that are covered services are extended psychiatric services.

(yyyy) "Revenue codes." Revenue codes as used in the UB-92 Manual. The UB-92 Manual may be obtained from the Wyoming Hospital Association (WHA), 2005 Warren Ave., Cheyenne, WY 82001.

(zzzz) "Routine care." Covered services other than ancillary care and those services included within any other level of care and other than specialty services.

(aaaaa) "Settled cost report." A hospitals cost report which has:

(i) Been submitted to Medicare in accordance with Medicare standards and procedures;

(ii) Cost settled by the Medicare intermediary using Medicare principles of cost reimbursement (a cost report is considered settled notwithstanding a request to reopen);

(iii) For which a notice of program reimbursement has been issued; and

(iv) For which a notice of Medicaid program reimbursement has been issued.

(v) A cost report is settled notwithstanding a request to reopen.

(bbbbb) "Services." Inpatient hospital services.

(ccccc) "Specialty services." "Specialty services" as defined by Chapter 31, which definition is incorporated by this reference.

(ddddd) Statewide. All participating providers.

(eeeee) "Survey agency." The Office of Health Care Quality of the Department, its agent, designee or successor, or a comparable agency in another state.

(fffff) "Swingbed." A bed in a hospital which is certified for either inpatient hospital services or nursing facility services.

(ggggg) "Swingbed services." Nursing facility services provided to a recipient in a swing-bed that are reimbursed pursuant to Chapter 28.

(hhhhh) "Technical denial." "Technical denial" as defined in Chapter 39, which definition is incorporated by this reference.

(iiiii) "Third party liability." Third party liability as determined pursuant to Chapter 4, which is incorporated by this reference.

(jjjjj) "Transfer." The act by which an individual that has been admitted to a hospital is released from that hospital to be admitted to another hospital. Transfer does not include movement of a patient to or from a distinct part hospital unit of the hospital or from one unit to another within a hospital.

048-30 Wyo. Code R. § 30-4