What's New

Utilization Management and Health Management Services Transition

Attention Wyoming Medicaid Providers:

As identified in the Wyoming Medicaid Provider Bulletin issued on March 1, 2022, WYhealth Utilization Management (UM) Services including prior authorizations (PAs) will be transitioned from the current vendor, Optum, to a new vendor, Telligen, effective July 1, 2022.

Health Management functions under the WYhealth program will be transitioning to a hybrid State-run program in cooperation with Telligen and Mountain-Pacific.

The Utilization Management services include prior authorizations for:

  • Physical/Occupational/Speech Therapy over threshold limits
  • Outpatient Behavioral Health Services over threshold limits
  • Home Health Services
  • Durable Medical Equipment and Prosthetics and Orthotics (DMEPOS)
  • Skilled Nursing Services for Waiver Plans
  • PRTF Admissions and Continued Stay Reviews
  • Dental Services including Severe Malocclusion Program
  • Surgical Procedures
  • Transplants
  • Genetic Testing
  • Title 25 Inpatient Stays
  • Inpatient Behavioral Health Admissions and Continued Stay Reviews
  • Vision Services
  • Unlisted Procedure Codes

Additional Utilization Management Services transitioning to Telligen also include:

  • Post Pay Claims Reviews
  • Mortality Reviews
  • Inpatient Census Reports
  • PASRR II Evaluations
  • Disability Determinations

In preparation of the upcoming transition of WYhealth from Optum to Telligen, will institute the following:

  • Prior Authorization (PA) Blackout Period Effective June 16, 2022:
    • A two-week blackout period starting June 16, 2022, 5 pm MTN at which point the current vendor, WYhealth, will cease in accepting prior authorizations (PAs).
    • Emergent/urgent requests for Acute I/P BH and PRTF admissions and CSRs, PASRR, and SNF ECC requests received through iExchange and fax will be processed until June 27, 2022, at 5 pm MTN.
    • WYhealth will discontinue enrolling providers in the iExchange system starting June 13, 2022.
  • Last day to submit Inpatient Census Reports (ICRs) to WYhealth is June 17, 2022.
  • WYhealth customer service toll free number 1-888-545-1710 will transition to WDH on June 30, 2022, 5 pm MTN.
  • The provider and member website, WYhealth.net, will shut down on June 30, 2022, at 5 pm MTN.
  • Mail received after 5 pm MTN on June 16, 2022, will be returned to the sender.
  • WYhealth email addresses, wyhealthinfo@optum.com and wyhealth@optum.com will be turned off at 5 pm MTN on June 30, 2022.
  • WYhealth fax 1-888-245-1928 will be shut down at 5 pm MTN on June 30, 2022.

Please watch for communication from WDH/Telligen, or you can visit https://wymedicaid.telligen.com which will be coming soon, regarding Utilization Management and Health Management services explaining processes effective July 1, 2022.

If you have any questions regarding the Utilization Management transition, please contact Amy Buxton, Utilization Management Coordinator and Contract Manager for Wyoming Medicaid via email at amy.buxton@wyo.gov.

Questions regarding the Health Management functions or the WYhealth program transition can be directed to Sarah Hoffdahl, Health Management Coordinator and Contract Manager for Wyoming Medicaid via email at sarah.hoffdahl@wyo.gov.

Nursing Facilities and Swing Beds

RE: Private rooms

Section 19.1.1 of the Wyoming Medicaid Institutional Provider Manual states:

Medicaid reimburses for room and board for a semi-private room which is included in the per diem.

If a member wishes to stay in a private room within the nursing facility, the facility and member have the following options:

  • The facility can choose to bill Medicaid as normal, and accept the semi-private room reimbursement amount as payment in full for the private room

    OR

  • The member or responsible party for the nursing home member can choose to pay for the private room in full, not the difference between the semi-private room and private room rates

Important! The nursing home may not “balance bill” the member for the cost difference between the semi-private and the private room and then submit a claim to Medicaid for the semi-private room.

This policy prohibits a Medicaid member or a responsible party (such as a spouse or parent of a minor child) from paying a provider facility the cost difference between a semi-private and private room and reimbursement above the Medicaid Allowable Payment.

This policy does not prohibit a payment by a non-responsible third party to upgrade the member from a semi-private room to a private room, provided that cost-difference payment is made directly to the nursing facility and not paid through the member or responsible party.

Wyoming Medicaid allows this form of direct third-party payment for several reasons:

  • First, because the practice of upgrading to a private room is technically not considered “balance billing” for a semi-private room paid by Medicaid
  • Second, because neither state or federal law, nor Wyoming’s Medicaid Provider Manual expressly prohibits these third party payments
  • Third, because the Medicaid program will not be charged the cost difference between the semi-private room and the private room, allowing the third party payment is revenue neutral to Medicaid and may be beneficial to the Medicaid member

If a Medicaid member requests a private room that is not medically necessary, the facility may directly charge a non-responsible third-party for the difference between the amount that Medicaid pays and the cost of the private room.

The third party must be clearly informed that there will be an additional charge, the amount of that charge, and that the choice of a private room with the additional charge is voluntary.

The facility must inform Medicaid that a third party payment is being made on behalf of the Medicaid member for the private room and the relation of the third party payer to the Medicaid member by contacting the county's Long Term Care (LTC) Eligibility case worker.

If you have any questions or concerns, please feel free to contact Amy Guimond at amy.guimond@wyo.gov or (307) 777-3427.

Professional Claims – Admission Date Required when Place of Service is Inpatient

Attention Practitioners and Billers:

A change in billing requirements is in effect for when a member is inpatient in a facility. This change now requires providers/practitioners to enter the member’s Admission Date to the facility on their Professional Claims or 837P claims transactions when the place of service is one of the following:

  • 21 – Inpatient Hospital
  • 51 – Inpatient Psychiatric Facility
  • 61 – Comprehensive Inpatient Rehab

BMS Provider Portal Direct Data Entry

The Admission Date field is located within the “Claim Information” section. Open the “Relevant Dates” dropdown by clicking on the “+” symbol.

Enter the Admit Date in the Admission Date fields.

The Place of Service must be selected from the available options in the dropdown box, including the following inpatient options:

  • 21 – Inpatient Hospital
  • 51 – Inpatient Psychiatric Facility
  • 61 – Comprehensive Inpatient Rehab

 

Note: Whenever an Inpatient-based Place of Service code is selected (21, 51 or 61) then the Admission Date is required.

The CMS-1500 Provider Manual will be updated in July to reflect this situational requirement in Chapter 6.4.1 Instructions for Completing the CMS-1500 Claim Form.

Severe Malocclusion Prior Authorization (PA) Units

Orthodontic providers may notice numerous adjustments and takebacks on their most recent Remittance Advice (RA). These are due to issues in which the new Benefit Management System (BMS) was erroneously counting units for CDT code D8670, which had been billed at $0.

In order to correct the number of units on the prior authorizations (PAs), CNSI voided all such claims which had processed since implementation. These adjustments should be seen on the most recent RA from April 15, 2022.

Wyoming Medicaid will then process the claims through the new BMS again so that all units are up to date and accurate in accordance with Wyoming Medicaid policy. If within the next couple of weeks, a claim does not appear to have been reprocessed, please contact Provider Services at 1-888-WYO-MCAD (1-888-996-6223).

Update to Covered Services

Attn: Federally Qualified Health Center (FQHC) providers

Reimbursement is available for one encounter per day per eligible member unless it is necessary for the member:

  • To be seen by different health professionals with different specialties; or
  • To be seen multiple times per day due to unrelated diagnoses
    • When a member is seen by providers of the same specialty within the same visit, services rendered are reimbursable as one face-to-face encounter

A medical visit is a face-to-face encounter between a member and a:

  • Nurse Practitioner
  • Nurse Midwife
  • Physician
  • Physician’s Assistant

Medical visits can also consist of:

  • Medical Nutrition Therapy
  • Diabetes Outpatient self-management training

A dental visit is a face-to-face visit between a member and a:

  • Dentist
  • Orthodontist
  • Dental care team specialist supervised by one of the above

Other health visits are a face-to-face encounter between a member and a:

  • Clinical Psychologist
  • Clinical Social Worker
  • Other health professional for mental health services

Maternity Billing – Postpartum Care Visits

Attention Maternity Services Providers:

Wyoming Medicaid has evaluated claims data and has determined that only approximately 40 percent of deliveries also have a matching postpartum visit billed. Postpartum care is a critical necessity after the delivery of a baby.

As a reminder, Wyoming Medicaid has separated the postpartum visit from maternity global bundle codes (59400, 59510, 59610, 59618). As part of this unbundling, the rate for these global codes was reduced by the allowed amount for the postpartum visit. This means that if providers only bill the global code, they will not receive any reimbursement for either of the recommended postpartum care visits. Providers must also bill for the postpartum visit or visits when they occur using code 59430.

Please note: Wyoming Medicaid supports the recommendation by the American College of Obstetricians and Gynecologists (ACOG) that at least two postpartum visits are provided.

Please review the Medicaid Pregnancy and Postpartum Care Billing Infographic for guidance on billing for maternity care under Wyoming Medicaid.

In circumstances where a member has a primary insurance which pays the full global rate including postpartum care, Wyoming Medicaid will still allow a provider to bill separately for the postpartum visit(s) using code 0503F. These claims will only pay if there is a claim in the system with a maternity global bundle code showing the primary insurance has paid on the claim.

Every person who delivers a baby should have at least one claim with either code 59430 or 0503F in the Medicaid system.

For any questions regarding this policy, please contact Amy Buxton at amy.buxton@wyo.gov.

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