048-40 Wyo. Code R. § 40-13

Current through April 27, 2019

Section 40-13 - Medicaid allowable payment for covered services

(a) In General. The Department reimburses for covered services provided to recipients under age twenty-one using an all-inclusive, negotiated, per diem rate determined pursuant to this Section.

(b) The Department may negotiate a separate rate for recipient's for whom Medicaid reimbursement is sought. The rate shall be the facility's base plus the reasonable, documented costs of providing medically necessary services as set forth in the plan of care requirements.

• (i) Before beginning negotiations, the provider shall submit to the Department in the format prescribed by the Department;
  • (A) Its base rate;
  • (B) A proposed rate; and
  • (C) Supporting documentation, including:
    • (I) The plan of care for the individual;
    • (II) The services in addition to room and board which are medically necessary to meet the goals of the plan of care; and
    • (III) The additional cost the facility will reasonably and necessarily be incurring to provide the additional services.

• (ii) The Department may request, and the provider shall furnish before a rate is established, additional information to document the medical necessity of the proposed services, added costs of furnishing those services, or both.

• (iii) The rate shall be the rate agreed upon by the provider and the Department. The rate shall apply to all services furnished to the recipient unless otherwise agreed by the Department.

• (iv) The Department may establish monitoring criteria and procedures to determine whether the services are being furnished.

(c) All inclusive. The negotiated rate shall be an all inclusive per diem rate for all services and supplies furnished by the facility, except as otherwise agreed by the Department.

(d) Maximum rate. The negotiated rate shall not exceed the facility's usual and customary rate.

(e) The Department's refusal to agree to a rate requested by a provider is not an adverse action for purposes of Chapter 1.

048-40 Wyo. Code R. § 40-13