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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyWyoming Medicaid Prior Auth Policy Update | OpenPa…
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    CurrentWyoming Department of HealthPolicy 048.0037.3.04072022

    Provider Enrollment and Participation, Pre-Authorization, Payment and Submission of Claims by Providers

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    This chapter governs enrollment and participation of providers in the Wyoming Medicaid program, prior authorization, Medicaid payment, and submission of claims. It applies to all Medicaid clients and providers for all furnished Medicaid services, subject to other Department rules.

    Policy Summary
    PayerWyoming Department of Health
    PolicyProvider Enrollment and Participation, Pre-Authorization, Payment and Submission of Claims by Providers
    Policy CodePolicy 048.0037.3.04072022
    Change TypeNo material change
    Effective DateApr 7, 2022
    Next Review DateNot specified
    Key ActionProviders must obtain prior authorization before furnishing services that require it and must use the forms specified by the Department.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    30 daysProvider enrollment application review
    5 yearsProvider enrollment duration
    6 yearsMedical and financial record retention
    12 months

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Standard claim submission deadline
    6 monthsCrossover or retroactive eligibility claim deadline
    10 daysRepayment after records request

    Eligibility, Authorization, and Payment Criteria

    Prior authorization approval criteria

    A timely prior authorization request must satisfy all applicable requirements below.

    ALL of the following

    • The service is medically necessary.
    • The service is consistent with the diagnosis and treatment of the client's condition.
    • The service is in accordance with standards of good medical practice among the provider's peer group.
    • The service is required to meet the client's medical needs and is undertaken for reasons other than client or provider convenience.
    • The service is performed in the most cost-effective and appropriate setting required by the client's condition.
    • The service meets additional criteria established by Wyoming Medicaid Rules or Department coverage policies.

    Provider enrollment requirements

    A provider must satisfy the following minimum requirements to enroll and remain eligible for Medicaid participation.

    ALL of the following

    • Meet applicable licensing and certification standards in the relevant state statutes and rules and, when applicable, Medicare certification standards.
    • Not be excluded from federally funded health care programs by the HHS Office of Inspector General.
    • Have an NPI assigned by the National Plan and Provider Enumeration System, as applicable.
    • Submit the Department's application and required qualification documentation.
    • Execute a provider agreement with the Department after approval.

    Claim payment and timely filing criteria

    Claims must meet the Department's submission requirements to support payment and avoid denial or voiding.

    ALL of the following

    • The claim is submitted on the Department-specified forms and in the required manner.
    • Required documentation and signatures were completed before claim submission.
    • The claim includes a prior authorization number when applicable.
    • The claim includes a valid client Medicaid identification number.
    • The claim includes a valid provider NPI and taxonomy, including the rendering provider when applicable.

    Coding, Filing, and Record Requirements

    Required provider and client identifiersmixedCovered
    NPIValid provider National Provider Identifier and taxonomy, including the rendering provider when applicable
    Client IDValid Medicaid identification number for the client of service
    Standard claim coding requirementsmixedCovered
    Billing codesValid billing codes established by the Department
    Diagnosis codesValid diagnosis codes established by the Department
    Billing code unitsAppropriate billing code units established by the Department
    Provider enrollment application determination
    Department determinationWithin 30 calendar days of receiving the application and all necessary qualification documentation.
    Included informationThe determination period includes supplemental information requested by the Department.
    Application outcomeIf approved, the provider and Department execute a provider agreement; if denied, the applicant receives written notice in accordance with Wyoming Medicaid Rules Chapter 4.
    Change of ownership notice
    Advance noticeNotify the Department in writing no later than 60 days before the proposed effective date of a change in ownership, control, operation, management contract, or leasehold interest.
    Prospective owner enrollment

    Required Provider Actions

    Prior Authorization

    Obtain Prior Authorization Before Service

    Before providing services that require prior authorization, request authorization using the forms specified by the Department.

    • Obtain authorization before the service is provided.
    • Use the Department-specified prior authorization forms.
    Denial Risk

    Authorization Is Required for Reimbursement

    Prior authorization is a prerequisite for Medicaid reimbursement when required. Failure to obtain authorization before providing the service precludes reimbursement, and authorization does not guarantee the client's eligibility or Medicaid payment.

    • Do not provide a service requiring prior authorization until authorization is obtained.
    • Verify client eligibility and other payment requirements separately.

    Terms and Claim Definitions

    Standard terminology
    Default ruleUnless otherwise specified in Wyoming Medicaid Rules Chapter 1, terminology used in this chapter has its standard meaning.
    Health care usageThe standard meaning is the meaning used in health care, Medicaid, and Medicare.
    Related rulesWyoming Medicaid Rules Chapter 1 may specify a different meaning.
    Clean claim
    Client identificationA clean claim includes a valid client identification number for the client of service.
    Provider identificationA clean claim includes a valid provider NPI number and taxonomy, including the rendering provider as applicable.
    Policy Summary
    PayerWyoming Department of Health
    PolicyProvider Enrollment and Participation, Pre-Authorization, Payment and Submission of Claims by Providers
    Policy CodePolicy 048.0037.3.04072022
    Change TypeNo material change
    Effective DateApr 7, 2022
    Next Review DateNot specified
    Key ActionProviders must obtain prior authorization before furnishing services that require it and must use the forms specified by the Department.
    SourceLink
    On This Page
    Eligibility, Authorization, and Payment CriteriaCoding, Filing, and Record RequirementsRequired Provider ActionsTerms and Claim Definitions
    The claim includes valid billing and diagnosis codes and appropriate billing code units.
  1. The claim includes other fields and documentation required for a clean claim.
  2. The claim is submitted within the applicable timely filing period.
    3. The prospective owner must enroll as a Medicaid provider to seek reimbursement for Medicaid covered services.
    Billing restrictionA new owner may not bill claims until the sale or transfer is effective and the owner is enrolled as a Medicaid provider.
    Medical and financial record retention
    Minimum retention periodMaintain medical and financial records for at least 6 years after the end of the state fiscal year in which payment for services was rendered.
    Records coveredRecords include dates of service, diagnoses, services furnished, and claims.
    Longer retentionIf litigation, a claim, an audit, or another action involving the records begins before the six-year period expires, retain the records until the matter and any subsequent administrative or legal proceedings are resolved.
    Hard-copy record retention
    Hard-copy periodMaintain records in hard copy for 3 years.
    Electronic transitionAfter 3 years, records may be maintained on microfiche, microfilm, or electronically.
    Retention obligationThe format change does not eliminate the applicable medical and financial record retention requirements.
    Repayment after failure to produce records
    Repayment deadlineRepay Medicaid payments within 10 days after the Department's written request when required records are not produced.
    Payment suspensionRefusal to make financial or medical records available results in immediate suspension of all Medicaid payments, including payments for services furnished after the request date.
    Suspension releasePayments remain suspended until the Department determines that adequate records have been produced and maintained.
    Standard timely claim submission
    Submission deadlineSubmit and finalize standard claims on or before 12 months after the date of service or the date of discharge, whichever is later.
    Late claimsThe Department shall deny claims that are not timely submitted.
    Applicable claimsThis deadline applies to standard processing claims, except for Medicare crossover and retroactive eligibility claims subject to separate deadlines.
    Medicare crossover claim submission
    Submission deadlineSubmit Medicare crossover claims within 6 months after the date Medicare acts on the claim.
    Claim typeThe exception applies to Medicare crossover claims.
    Timely filing consequenceClaims not submitted within the applicable timely filing period are subject to denial.
    Retroactive eligibility claim submission
    Submission deadlineSubmit retroactive eligibility claims within 6 months after the date retroactive eligibility is determined.
    Triggering dateThe filing period begins on the date of the determination of retroactive eligibility.
    Timely filing consequenceClaims not submitted within the applicable timely filing period are subject to denial.
    Prior Authorization

    Meet Medical Necessity Criteria

    Support the prior authorization request by demonstrating that the proposed services meet the Department's medical-necessity and coverage requirements.

    • The services are medically necessary.
    • The services are consistent with the diagnosis and treatment of the client's condition.
    • The services accord with good medical practice standards among the provider's peer group.
    • The services meet the client's medical needs and are undertaken for reasons other than client or provider convenience.
    • The services are provided in the most cost-effective and appropriate setting for the client's condition.
    • The services meet additional criteria in Wyoming Medicaid Rules or Department coverage policies.
    Documentation Required

    Respond to Documentation Requests

    Respond to Department or designee requests for additional information or documentation needed to determine whether prior authorization requirements are met. After submitting the requested documentation, the provider may request further review of the authorization request.

    • Provide all requested information and supporting documentation.
    • Use the available further-review process after submitting additional documentation.
    Billing Rule

    Report the Authorization Number on Claims

    When applicable, include the prior authorization number on claims submitted to the Department, along with the other documentation and claim information required by the applicable Medicaid provider manual.

    • Report the prior authorization number when the service required prior authorization.
    • Include other records or documentation requested by the Department.
    Coding and units
    A clean claim includes valid billing and diagnosis codes and appropriate billing code units established by the Department.
    Additional requirementsA clean claim includes other provider or specific claim fields required by the Department.