048-35 Wyo. Code R. §§ 35-8 - Payment or Rejection of Medicaid Claims Subject to Third Party Liability

(a) Probable existence of liability of third party payer established at time of Medicaid claim. If the Department has established the probable existence of liability of a third party payer at the time a provider submits a Medicaid claim, the Department shall reject the Medicaid claim and return it to the provider for a determination of the amount of such liability.

(b) Establishing probable existence of liability of a third party payer. The probable existence of liability of a third party payer is established when the Department receives information from any source confirming the existence and extent of liability of a third party payer. When the amount of liability is established, the Department shall process and pay Medicaid claims involving third party liability only to the extent that the Medicaid payment allowed by the Department's normal procedures and standards exceeds the amount of the third party payer's liability.

(c) Unavailability of third party payments. Third party payments are not available at the time of the submission of a Medicaid claim if the existence and extent of third party payer liability is still disputed. If third party payments are not available, the Department shall process Medicaid claims subject to its normal procedures.

(d) Reconsideration. A provider may request that the Department reconsider a decision to recover payments because of third party liability. Such request shall be made and shall be handled pursuant to the reconsideration provisions as set forth in Chapter 3, Section 14, of the Wyoming Medicaid Rules.

(e) Denial of improper claims. The Department shall deny claims which are improperly submitted or which contain errors of any kind. Denied claims may be resubmitted, subject to applicable federal and state requirements, including Chapter 1 and Chapter 16.

Notes

048-35 Wyo. Code R. §§ 35-8

Amended, Eff. 2/19/2019.