Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesHome Health & HospiceWyoming Medicaid Nursing Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentWyoming Department of HealthPolicy HCBS-2020-CB01

    Additional Guidance for the Prior Authorization of Waiver Skilled Nursing Services

    Customize your policy alerts

    Sign up for Wyoming Department of Health Policy HCBS-2020-CB01 alerts

    Get alerted when Policy HCBS-2020-CB01 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Governs utilization review, documentation, and prior authorization of skilled nursing services provided through Wyoming Medicaid Home and Community-Based Services waiver programs.

    Policy Summary
    PayerWyoming Department of Health
    PolicyAdditional Guidance for the Prior Authorization of Waiver Skilled Nursing Services
    Policy CodePolicy HCBS-2020-CB01
    Change TypeNo material change
    Effective DateMay 13, 2020
    Next Review DateN/A
    Key ActionObtain prior authorization before waiver skilled nursing services are authorized or delivered.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3HCBS waiver programs with skilled nursing
    6 business daysMissing-documentation deadline
    30 daysSecond-review deadline
    RNPA form and visits completed by

    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.

    19+ / 21+
    Review age thresholds
    52 visits/yearExample annual visits

    Coverage Criteria

    General coverage and medical necessity

    Waiver skilled nursing is appropriate when all applicable conditions are met.

    Covered waiver skilled nursing request

    • Clinical and benefit requirements

      • Assessed need: The service is consistent with the participant's comprehensive assessment and documented functional limitations or skilled nursing needs.
      • Adequate care plan: The care plan adequately describes the planned interventions, visit frequency, visit length, duration, and justification for nursing care.
      • Nonduplication: The service does not duplicate Medicaid State Plan services or other waiver services and supplements rather than replaces State Plan home health.
      • Community setting need when applicable: If services are requested in the community, the participant requires assistance to participate in community activities or access other community services.

    • Participant-specific justification

      • Participant cannot self-care: The participant is not capable of safely completing the requested task independently.
      • Natural supports unavailable or inappropriate: Natural supports are not willing, able, available, or appropriate, considering the participant's individual circumstances, dignity, and privacy.
      • Local access or workforce barrier: The care plan adequately documents local provider-network or workforce limitations, or limited accessibility of other healthcare services, when those factors justify waiver nursing rather than a lower-level or outpatient service.

    Program and age eligibility

    The following program and age-routing criteria apply.

    Program and age routing

    • Applicable waiver program

      • Community Choices Waiver: The participant is enrolled in the Community Choices Waiver and is age 19 or older.19+
      • Comprehensive or Supports Waiver: The participant is enrolled in the Comprehensive or Supports Waiver and is age 21 or older.21+

    Medically necessary skilled nursing services for individuals under age 21, including long-term services, must be provided through the Medicaid State Plan in accordance with EPSDT coverage requirements rather than through the waiver skilled nursing benefit.

    Waiver skilled nursing services do not include companionship or services that are diversional or recreational in nature.

    Participant transportation costs are not part of waiver skilled nursing services and must be billed separately.

    Waiver skilled nursing services supplement, but do not replace, home health services furnished under the Wyoming Medicaid State Plan.

    Waiver skilled nursing services should not be authorized when the participant can complete the requested care independently or when natural supports are willing, able, available, and appropriate to provide it. The participant’s individual circumstances, dignity, and privacy must be considered.

    Services that duplicate other waiver services or Medicaid State Plan services are not medically necessary for authorization under the waiver skilled nursing benefit.

    Coding and Review Parameters

    Community Choices Waiver skilled nursingHCPCS
    S9123Community Choices Waiver uses HCPC code S9123 (1-hour code)
    Comprehensive and Supports Waiver skilled nursingHCPCS
    T1002Comprehensive and Supports Waivers use HCPC T1002
    Community Choices Waiver review age
    Review populationParticipants age 19 and older
    Waiver programCommunity Choices Waiver
    Review authorityComagine Health reviews skilled nursing waiver services for this population
    Comprehensive and Supports Waiver review age
    Review populationParticipants age 21 and older
    Waiver programsComprehensive Waiver and Supports Waiver
    Under age 21

    Provider Actions and Authorization Requirements

    Prior Authorization

    Prior Authorization Required Before Service

    Prior authorization is required before waiver skilled nursing services are authorized or delivered. Requests cannot be backdated; submit the request before services begin.

    Billing Rule

    Community Choices Waiver Billing Code

    Use the applicable HCPCS code when requesting Community Choices Waiver skilled nursing services.

    • S9123 — Community Choices Waiver, 1-hour code.

    Program Background

    Waiver skilled nursing services provide part-time or intermittent nursing care within the scope of practice and required to be delivered by a registered nurse under the Wyoming Nurse Practice Act. The benefit is available to eligible HCBS waiver participants and may support long-term skilled nursing needs in the home or community.

    Definitions

    Waiver skilled nursing services
    DefinitionPart-time or intermittent skilled nursing care within the scope of practice under the Wyoming Nurse Practice Act
    Required practitionerA registered nurse must deliver the service
    Service settingServices may be provided in the home or in the community when the participant requires assistance to participate in community activities or access other community services
    State Plan home health services
    DefinitionMedicaid home health services furnished under 42 CFR §440.70
    Relationship to waiver servicesWaiver skilled nursing services extend and supplement State Plan home health services
    Policy Summary
    PayerWyoming Department of Health
    PolicyAdditional Guidance for the Prior Authorization of Waiver Skilled Nursing Services
    Policy CodePolicy HCBS-2020-CB01
    Change TypeNo material change
    Effective DateMay 13, 2020
    Next Review DateN/A
    Key ActionObtain prior authorization before waiver skilled nursing services are authorized or delivered.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Review ParametersProvider Actions and Authorization RequirementsProgram BackgroundDefinitions
    Medically necessary skilled nursing services must be provided under the Medicaid State Plan in accordance with EPSDT requirements
    Missing-documentation submission period
    Submission periodWithin 6 business days after Comagine Health requests missing information through the provider portal
    Notification methodComagine Health notifies the provider through the provider portal
    Failure to submitThe request receives a technical denial
    Second-review request period
    Request periodWithin 30 days of the decision
    How to requestSubmit the second-review request through the provider portal
    Applicable decisionsDenied or reduced services
    Example annual visit calculation
    Weekly frequency1 visit per week
    Visit length1 hour
    Annual calculation1 visit per week × 1 hour × 52 weeks = 52 visits per year
    Billing Rule

    Comprehensive and Supports Billing Code

    Use HCPCS code T1002 for skilled nursing services under the Comprehensive and Supports Waivers.

    • T1002 — Comprehensive and Supports Waivers.

    Unsupported block type: prior_auth

    Note

    Age and Program Routing

    Route the participant to the applicable waiver and coverage pathway based on age. Participants under age 21 must receive medically necessary skilled nursing through the Medicaid state plan under EPSDT requirements.

    • Community Choices Waiver: participants age 19 and older.
    • Comprehensive and Supports Waivers: participants age 21 and older.
    • For participants under 21, use state plan coverage and EPSDT rather than waiver skilled nursing coverage.
    Documentation Required

    Modification Requests

    For a modification during the current plan year, submit an updated PA form explaining the change and identify the current authorization. The modification adds to, rather than replaces, the existing approved authorization.

    • Include the current approved visit frequency and duration.
    • MD orders are valid for up to one year; new modification orders are not needed if the original order remains valid and meets requirements.
    • Provide the rationale in Box 16, such as a recent hospitalization or new diagnosis.
    Note

    Review and Appeal Pathway

    If you disagree with a denial or reduction, request a second review through the provider portal within 30 days of the decision. If the disagreement remains after second review, the skilled nursing provider must notify the case manager and provide the denial or reduction notice; the participant may request Medicaid reconsideration and a Fair Hearing within the applicable 30-day period.

    • Monitor provider-portal alerts for requests for additional information and status changes.

    Unsupported block type: documentation

    Documentation Required

    Assessment and Care Plan Content

    The provider must complete a comprehensive assessment of the participant's needs and develop a detailed nursing care plan for UM review. The submission must explain how the requested services match assessed needs and describe the planned interventions adequately.

    • Include frequency, visit length, and duration, with calculations supporting the requested number of visits.
    • The care plan must show that skilled nursing supplements, rather than replaces, other services.
    • The UM vendor reviews the requested waiver skilled nursing services and does not determine necessity or appropriateness for unrelated medical services.
    Documentation Required

    Functional, Support, and Access Justification

    Document the participant's functional limitations, ability to perform self-care, availability and willingness of natural supports, and the local access circumstances supporting community-based skilled nursing.

    • Explain why the participant cannot safely or independently complete the requested tasks.
    • Identify whether natural supports are willing, able, available, and appropriate, while respecting the participant's dignity and privacy.
    • Address local provider-network or workforce limitations, accessibility of other healthcare services, outpatient-care barriers, and how the requested task integrates efficiently with the care plan.
    Documentation Required

    RN Signature Requirements

    The RN completing the PA form must hand-sign or use a digitally authenticated signature and date it. LPNs/LVNs may not sign or co-sign, and no one may co-sign for the RN who completed the form.

    Documentation Required

    Complete the PA Form Fully

    Complete every field on the PA form; enter N/A when appropriate. Ensure the requested frequency and duration match the information submitted in the provider portal.

    • Box 16 must include the participant's needs narrative, nursing interventions and justification, visit frequency, visit length, and duration.
    • Box 18 must include specific information about the participant's plan, including applicable supports or services such as assisted living or community living services.
    Documentation Required

    Service-Specific Clinical Detail

    Provide enough clinical detail to show why the requested intervention is needed and why the requested frequency and duration are appropriate for this participant.

    • Describe interventions tried or considered and any that failed; include recent unscheduled, urgent, or emergency visits, PCP visits, or admissions and their reasons.
    • For medication management, explain the skilled nursing function, why the participant cannot perform it, and whether blister or bubble packs were tried.
    • For foot care, labs, wound care, line or port care, and education, provide the relevant condition, assessment, access, frequency, duration, supplies, teaching plan, and current clinical details.
    Denial Risk

    Benefit Scope, Clinical Appropriateness, and Duplication

    Requests must be within the scope and limitations of the waiver skilled nursing benefit, clinically appropriate, consistent with Wyoming nursing practice, supported by assessed needs, and nonduplicative of Medicaid state plan or other waiver services.

    • Waiver skilled nursing supplements, but does not replace, state plan home health or other services.
    • The peer review evaluates the requested skilled nursing services and care plan; it does not authorize unrelated medical services or medication routes.
    • Services may be provided in the home or community when needed for community participation or access to other services.
    Denial Risk

    Self-Care and Natural Supports

    Do not request waiver skilled nursing when the participant can provide the care through self-care or when natural supports are willing, able, available, and appropriate to provide it.

    Denial Risk

    Justify Local Access Barriers

    A request may be denied if it does not adequately justify local access barriers. Explain network or workforce limitations, the availability and accessibility of local healthcare services, outpatient-care barriers caused by functional limitations, and the efficiency of integrating the task with community-based services.

    • Adequate documentation may prevent denial based solely on the fact that a task could be performed by a lower-level practitioner or is typically performed in an outpatient setting.
    Denial Risk

    Non-Skilled or Unrelated Services

    Waiver skilled nursing does not include companionship or diversional or recreational services. Participant transportation costs are not part of the skilled nursing benefit and must be billed separately.

    Denial Risk

    Missing Documentation

    If required information is missing, Comagine Health will request it through the provider portal. Failure to submit the requested documentation within 6 business days may result in a technical denial; the provider may resubmit when the documentation is complete.

    • Accepted attachment formats include Word documents, PDFs, and JPGs; TIF image files are not accepted.
    Coverage distinctionWaiver skilled nursing services supplement, rather than replace, State Plan home health services
    Initial request
    DefinitionA request for a new participant
    TimingMay be submitted at the beginning of the service-plan year or later in the plan year
    Service statusThe participant is new to the requested skilled nursing authorization
    Renewal
    DefinitionA request for an existing participant who received services during the prior year
    Participant statusThe participant already has a prior year of skilled nursing services
    Request typeThe request continues services for an existing participant
    Modification
    DefinitionA change to an existing authorization during the plan year
    Required submissionSubmit an updated prior authorization form with the rationale for the change
    Current authorizationIdentify the currently approved frequency and duration; additional authorization is added to, rather than replacing, the existing authorization