048-9 Wyo. Code R. §§ 9-11 - Service limitations

(a) Outpatient hospital services.

(i) Generally. Medicaid reimbursement for outpatient hospital services shall be limited to a total of twelve visits per calendar year to a hospital clinic, a hospital emergency room (for non-emergency services), and/or a physician's office, unless additional visits are prior authorized.

(ii) Physical therapy services. Medicaid reimbursement for physical therapy services shall be limited to a total of twenty visits per calendar year to a hospital, independent physical therapist or a physicians office, unless additional visits are prior authorized.

(b) Provider's responsibilities.

(i) Determining number of days and visits. Providers are responsible for determining whether a recipient has exceeded the limitations specified in subsections (a).

(ii) A provider which furnishes hospital services which are not covered services or which are in excess of service limitations shall not receive Medicaid reimbursement for such services. The provider may charge the recipient for any such excess services if the provider notified the recipient, in writing, before the services were provided that such services are not covered by Medicaid and that the provider will seek reimbursement from the recipient, and the recipient agrees, in writing, to pay for such services before they are provided. This paragraph does not apply to services provided in excess of the service limitations of this Section.

(c) Exceptions. The limitations of subsections (a) shall not apply to:

(i) Ancillary services;

(ii) Recipients under age twenty-one;

(iii) Emergency hospital services;

(iv) Services that are prior authorized; or

(v) Recipients that are also eligible for Medicare.

Notes

048-9 Wyo. Code R. §§ 9-11