wy medicaid behavior health program administration · medical records and analyzed overall provider...
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PROGRAM MONITORING AND EXPENDITURES
WY Medicaid coverage of behavioral health services is an optional program benefit for adults and a
mandatory program benefit for children under the age of 21. The state of Wyoming has elected to cover
eligible behavioral health services for both adults and children pursuant to federal and state regulations
and guidelines. As part of the program’s routine monitoring of provider participation, client utilization,
coding/billing and expenditures, it was noted that there were significant changes in program data
throughout 2015 and 2016 that suggested potential compliance challenges.
The WY Medicaid Annual Report showed an 18% increase in spending on covered behavioral
health services over a 5 year timeframe
The WY Medicaid PMPM Report showed an increase in the PMPM for behavioral health services
from $32.19 PMPM in SFY 2012 to $43.17 PMPM in SFY 2016
In SFY 2014 and SFY 2015, there was legislative action directed at expanding qualified provider
participation in Medicaid.
2014 SEA 49 – provided authority for the following licensed practitioners to enroll and receive
payment from Medicaid; Licensed Clinical Social Workers, Licensed Professional Counselors,
Licensed Addictions Counselors, Licensed Marriage and Family Therapists
2015 SEA 21 – provided authority for provisional level practitioners working under the
supervision of a licensed mental health clinician to enroll and receive payment from Medicaid
Consistent with routine data monitoring and post-payment review processes, WY Medicaid staff
completed a number of detailed provider-specific coding/billing trend analyses, reviewed charts and
medical records and analyzed overall provider reimbursement detail for compliance with federal and
state program rules and regulations. Post-payment reviews conducted during this time frame resulted
in the referral of over 50 behavioral health service providers to the program integrity unit for further
investigation and potential overpayment recovery action. Important to note, from the receipt of a
referral through an overpayment recovery (or case closure), it can take up to 225 days to fully resolve an
open case. Additional time may also be necessary for reviewing provider appeals or working through
administrative hearings. In most cases, throughout the course of the investigation, the provider
continues receiving payment from Wyoming Medicaid until a final case determination is rendered.
These timelines exclude cases that, upon state review, are referred to other federal and/or criminal
entities (Medicaid Fraud Control Unit, FBI, DCI or the OIG) for administrative and legal support.
In SFY 2016, and in response to declining state fund revenue, the Wyoming Department of Health
Budget was reduced by $90 million general fund, with $54.4 million general fund coming from the WY
Medicaid program. Given the financial relationship of the WY Medicaid program with its federal
counterpart, a loss of $54.4 million general fund resulted in an equitable loss of matching federal
dollars. WY Medicaid program staff were required to evaluate and adjust all aspects of program
administration, coverage and reimbursement in order to work within the confines of a reduced budget.
As noted in a June 2016 correspondence from the WDH Director, steps taken to implement the
reductions were identified based on several key principles –
Avoid across the board reductions
Distribute reductions throughout the agency
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Reduce administrative costs where possible
Minimize impact on safety net services
Minimize impact on programs that provide services to a broader population vs. a narrower
population
Minimize impact on vulnerable provider groups
Evaluating measures that could be taken to monitor spending, in conjunction with the increase
in compliance concerns noted within the behavioral health service line, WY Medicaid made the
decision to administer the benefit and monitor compliance through a prior authorization process as
opposed to a post-pay review process. The benefit administration change was not intended to deny
appropriate services to Medicaid beneficiaries, but to confirm service compliance prior to rendering
payment.
Over the course of the benefit administration change, the clinical criteria for WY
Medicaid coverage of behavioral health services for both adults and children has remained
the same. No changes have been made to service definitions, clinical coverage criteria or
documentation and retention requirements.
Based on continuous monitoring and feedback from Qualis Healthcare, LLC as the entity
contracted to conduct the clinical reviews on behalf of the program, WY Medicaid staff have worked
diligently to provide technical assistance documents, webinar training, policy reminder bulletins,
FAQ documents, and helpful tips and hints for achieving and maintaining ongoing compliance with
existing service coverage criteria and documentation requirements.
SERVICE UTILIZATION AND PAYMENT TRENDS
Service Unit Trends
SFY2016 SFY2017 SFY2018 SFY2019 SFY2016 vs SFY2018 Notes
2016 is ___% of 2018101YA0400X Licensed Additions Therapist 5,500 14,407 10,307 470 187.40%
101YP2500X Licensed Professional Counselor 178,389 234,427 218,431 38,332 122.45%
103G00000X Clinical Neuropsychologist 23 145 307 87 1334.78%
103TC0700X Clinical Psychologist 858,034 426,907 261,748 59,077
30.51% Decrease 2 Fraud Cases and 3 Pending
1041C0700X Licensed Clinical Social Worker 112,289 149,087 161,541 32,407 143.86%
106H00000X Licensed Marriage and Family Therapist 13,718 12,472 16,887 3,690 123.10%
2084P0800X Psychiatrist 110,421 101,319 96,007 13,205
86.95% Decrease Shortage of providers in Wyoming
261QM0801X Community Mental Health Center 648,979 503,640 373,146 57,208
57.50% Decrease
Increase in community based
providers through legislative
action
261QR0405X Substance Abuse Treatment Center 295,960 210,817 219,398 27,039
74.13% Decrease
Increase in community based
providers through legislative
action
364SP0808X Advanced Practice Registered Nurse, Psych 5,610 6,333 6,355 1,110 113.28%
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Reimbursement Trends by Provider Type
Noted Observations based on data reviewed:
Legislative action taken in SFY 2014 and SFY 2015 to expand the network of Medicaid enrolled
community based behavioral health providers impacted service units billed and overall Medicaid
reimbursement to Community Mental Health Services (CMHCs) and Substance Abuse Treatment
Centers (SATCs)
To the extent Medicaid reimbursement and services provided decreased at CMHCs and SATCs,
units of service and total reimbursement to other types of licensed and enrolled practitioners
increased
WY Medicaid’s efforts to identify and pursue action against providers billing inappropriately
resulted in a significant decrease in reimbursement in the area of clinical psychology services
The low number of licensed and enrolled psychiatrists in Wyoming continues to be a concern, and
is insufficient for the service demand identified
PROVIDER ENROLLMENT AND REIMBURSEMENT
SFY2016 SFY2017 SFY2018 SFY2019 SFY2016 vs SFY2018
2016 is ___% of 2018101YA0400X Licensed Additions Therapist 113,353.88$ 240,747.37$ 210,775.55$ 14,400.73$ 185.94%
101YP2500X Licensed Professional Counselor 3,999,103.96$ 5,489,663.74$ 4,884,797.59$ 831,123.86$ 122.15%
103G00000X Clinical Neuropsychologist 1,894.11$ 23,325.99$ 69,329.21$ 8,803.46$ 3660.25%
103TC0700X Clinical Psychologist 13,495,523.00$ 7,667,549.09$ 5,578,450.92$ 1,138,296.56$
41.34% Decrease 2 Fraud Cases and 3 Pending
1041C0700X Licensed Clinical Social Worker 2,628,100.21$ 3,368,623.63$ 3,386,001.49$ 670,337.81$ 128.84%
106H00000X Licensed Marriage and Family Therapist 326,600.95$ 304,343.79$ 446,808.34$ 92,487.65$ 136.81%
2084P0800X Psychiatrist 2,668,105.38$ 2,709,112.04$ 2,422,235.76$ 308,575.46$
90.78% Decrease Shortage of providers in Wyoming
261QM0801X Community Mental Health Center 8,622,989.61$ 7,704,626.20$ 6,074,841.89$ 958,736.27$
70.45% Decrease
Increase in community based
providers through legislative
action
261QR0405X Substance Abuse Treatment Center 4,049,401.34$ 2,985,973.85$ 3,158,876.68$ 437,062.49$
78.01% Decrease
Increase in community based
providers through legislative
action
364SP0808X Advanced Practice Registered Nurse, Psych 280,151.10$ 331,153.73$ 362,134.32$ 69,652.74$ 129.26%
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WY MEDICAID COVERAGE POLICY FOR BEHAVIORAL HEALTH SERVICES
Wyoming Medicaid Coverage Policy
Provider Manual Effective 7/1/18 (prior versions available via the same link)
https://wymedicaid.portal.conduent.com/MHSA.html
Page 178 – 222
Wyoming Medicaid Rule
https://rules.wyo.gov/Search.aspx?mode=1
Chapter 13
Wyoming Medicaid State Plan
https://health.wyo.gov/healthcarefin/medicaid/spa/
Section 3.1A, 13D
A formal State Plan Amendment was completed in 2016 to add Medicaid coverage of Applied
Behavior Analysis services for children with autism under the age of 21, as well as to add
Medicaid authority to prior authorize behavioral health services after 20 dates of service. The
public notice for the proposed State Plan Amendment was released on 3/3/2016. WY Medicaid
received no public comments on the proposed benefit administration change.
UTILIZATION MANAGEMENT REQUIREMENTS
42 CFR 456.22 – Sample basis evaluation of services - To promote the most effective and
appropriate use of available services and facilities the Medicaid agency must have procedures for
the on-going evaluation, on a sample basis, of the need for and the quality and timeliness of
Medicaid services.
§ 456.2 State plan requirements.
(a) A State plan must provide that the requirements of this part are met.
(b) These requirements may be met by the agency by:
(1) Assuming direct responsibility for assuring that the requirements of this part are met; or
(2) Deeming of medical and utilization review requirements if the agency contracts with
a QIO to perform that review, which in the case of inpatient acute care review will also
serve as the initial determination for QIO medical necessity and appropriateness review
for patients who are dually entitled to benefits under Medicare and Medicaid.
(c) In accordance with § 431.15 of this subchapter, FFP will be available for expenses incurred in
meeting the requirements of this part.
§ 456.3 Statewide surveillance and utilization control program.
The Medicaid agency must implement a statewide surveillance and utilization control program
that -
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(a) Safeguards against unnecessary or inappropriate use of Medicaid services and against excess
payments;
(b) Assesses the quality of those services;
(c) Provides for the control of the utilization of all services provided under the plan in
accordance with subpart B of this part; and
(d) Provides for the control of the utilization of inpatient services in accordance with subparts C
through I of this part.
WY Medicaid, in accordance with federal law, is required to establish and implement processes
to monitor and assess for appropriate versus inappropriate service delivery and billing, as well as to
ensure services being paid for are medically necessary.
§ 440.230 Sufficiency of amount, duration, and scope.
(a) The plan must specify the amount, duration, and scope of each service that it provides for -
(1) The categorically needy; and
(2) Each covered group of medically needy.
(b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its
purpose.
(c) The Medicaid agency may not arbitrarily deny or reduce the amount, duration, or scope of a
required service under §§ 440.210 and 440.220 to an otherwise eligible beneficiary solely because
of the diagnosis, type of illness, or condition.
(d) The agency may place appropriate limits on a service based on such criteria as medical
necessity or on utilization control procedures.
DETERMINATION OF MEDICAL NECESSITY – CASE LAW
Applicable Case Law in the State’s Determination of “medically necessary services” –
CMS has indicated that states have great flexibility in defining the criteria for placing limits on a service
based on criteria such as medically necessary or utilization control procedures. In a 2002 response to a
comment suggesting CMS establish a Federal definition of medical necessity, CMS stated, “States have
flexibility to place appropriate limits on a service based on such criteria as medical necessity or on
utilization control procedures, and have great flexibility in defining those criteria. Therefore we do not
believe it is appropriate to promulgate a national definition [of medical necessity]” Department of Health
and Human Services; Medicaid Program; Medicaid Managed Care; New Provisions; Final Rule, 67 Fed.
Reg. 40989, at 41047.67 Federal Register 41047 (June 14, 2002) (codified at 42 CFR Parts 400, 430, 431, 424,
435, 438, 440, and 447) (emphasis added).
In a 2016 response to a comment suggesting CMS add the phrase “medically necessary” to 42 CFR
440.70(b), to read “Home Health services include the following medically necessary services and items,”
CMS responded, “We agree that states may limit covered services to only include medically necessary
services. This flexibility is already provided in regulation at § 440.230(d). Medical necessity is not
determined by us, but is determined by medical professionals. Many states employ medical professionals
to establish medical necessity criteria and then review individual circumstances in light of those criteria.
…” Department of Health and Human Services; Medicaid Program; Face-to-Face Requirements for Home
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Health Services; Policy Changes and Clarifications Related to Home Health; Final Rule, 81 Fed. Reg. 5530,
at 5534 (February 2, 2016) (codified at 42 CFR Part 440) (emphasis added).
WY Medicaid rules define medically necessary and/or medical necessity as:
“Medically necessary” or “medical necessity.” A health services that is required to diagnose, treat, cure,
or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected; to relieve
pain, or to improve and preserve health and be essential to life. The service must be:
(i) Consistent with the diagnosis and treatment of the recipient’s condition;
(ii) In accordance with the standards of good medical practice among the provider’s peer group;
(iii) Required to meet the medical needs of the recipient and undertaken for reasons other than
the convenience of the recipient and the provider; and
(iv) Performed in the most cost effective and appropriate setting required by the recipient’s
condition.
In accordance with federally mandated oversight of payment for services, WY Medicaid conducts
competitive procurements at various times to obtain resources for assessing prior authorization
requests and making a determination of compliance with (ii) listed above. WY Medicaid contracts with
nationally accredited Quality Improvement Organizations (QIOs as approved by CMS) to conduct
clinical reviews of services both prior to delivery (prior authorization) and after services have already
been paid for (post payment review).
Through 2015 and 2016, WY Medicaid became more aware of potential situations of inappropriate
service delivery and billing to WY Medicaid. Implementing the authority provided to the program in 42
CFR (above), WY Medicaid made the decision to move its oversight activities from a post-payment
review to a prior authorization. To a great extent, this change allowed WY Medicaid to evaluate the
compliance of services being provided prior to payment rather than work through a formal investigative
process and potential payment recovery.
WHAT IS A “QIO” AND WHO IS QUALIS HEALTH, LLC?
Qualis Health, LLC employs and utilizes clinically licensed reviewers as required to evaluate
prior authorization requests for medical necessity and therapeutic appropriateness in accordance with
the organization’s standard processes, and federal and state rules and regulations. Many of Qualis
Health’s clinical and operational requirements are governed by federal law as part of their national
Quality Improvement Organization (QIO) accreditation. These regulations are found at 42 CFR Part
476 and implement Section 1153 and Section 1154 of the Social Security Act. A first level review is
performed by a nurse reviewer using decision support criteria contained in a software product called
InterQual (computer based triage tool used to expedite approvable requests). For any requests not
approved by the first level reviewer, a second level review is completed by a physician (for medical
services) or a psychiatrist (for behavioral health services). Based on the psychiatrist’s training,
credentialing, experience and WY Medicaid coverage criteria, the documentation submitted is reviewed
to evaluate the clinical and therapeutic appropriateness (in amount, duration and scope) of the services
being requested. If the second level review upholds the initial denial, a letter is generated and the
provider is notified of the denial/partial denial.
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Qualis Health’s continued status as a nationally accredited QIO organization provides assurance
to WY Medicaid that administrative and clinical review processes meet the criteria outlined in federal
regulation.
Qualis Health, LLC was contracted to begin behavioral health prior authorization requests for
WY Medicaid starting with dates of service November 1, 2017 and forward. Qualis Health also conducts
prior authorization reviews on behalf of WY Medicaid for home health services, physical therapy,
occupational therapy, speech therapy and durable medical equipment. Optum, a second QIO entity
under contract with WY Medicaid to conduct prior authorization reviews, has oversight of all prior
authorization requests for psychiatric inpatient hospital admissions, psychiatric residential treatment
facilities for children under 21, and various surgical procedures such as back surgery, gastric bypass
procedures and vagal nerve surgery.
Prior to implementation, Qualis Health provided training to providers on their web portal,
provided information on the types of documents that would be required as part of the review, and
remained open to assisting providers with becoming comfortable with the request process.
As the volume of prior authorization requests increased in the spring of 2018, Qualis Health LLC
did fall behind in reviewing submissions timely. In accordance with their contracted service level
metrics, Qualis Health has been working under a Corrective Action Plan (CAP) with WY Medicaid staff.
On July 1, 2018, communication was issued by WY Medicaid that Qualis Health had been instructed to
prioritize their review of prior authorization requests to focus on those submitted timely by providers
(before the end of the existing treatment period). Prior authorization requests submitted late by
providers were reviewed subsequent to on time reviews. On Friday September 21, 2018, WY Medicaid
program staff approved an amended clinical review process designed to reduce the documentation
required from providers when submitting a prior authorization request as well as expediting the review
process.
PROVIDER NOTIFICATION AND EDUCATION REGARDING WY MEDICAID CHANGES TO
UTILIZATION MANAGEMENT ACTIVITIES
Electronic Communications
State Plan Public Notice, 3/3/16 – Notified providers of the State’s intent to request permission
to limit coverage to 20 dates of service and require a prior authorization through a clinical
review for ongoing service coverage
Revisions to Chapter 13 Rule – All public comment processes were followed to formally adopt
changes reflected in Section 7.
7/8/16 – Provider Bulletin
11/15/16 – Provider Bulletin
2017 Provider Training Workshops (Statewide w/WY Medicaid Staff) – Trainings attached
3/3/17 – Provider Bulletin
4/18/17 – Provider Bulletin RE: 2017 Provider Training Workshops
5/22/17 – Provider Bulletin
7/10/17 – Provider Bulletin
8/1/17 – Provider Bulletin RE: 2017 Provider Training Workshops
8/28/17 – Notification of shift to Qualis for prior authorization reviews
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10/5 & 10/12/17 – Provider Training on Qualis system (slides)
2/2/18 – Provider Bulletin
2/26/18 – Provider Bulletin
4/25/18 – Billing Workshop/ Training for WY Medicaid, Dates and Times (RA Banner)
4/25/18 – Billing Workshops, Provider Bulletin
5/20/18 – Wyoming Psychological Association Training/Update
5/21/18 – Billing Workshops, Provider Bulletin (Updated)
6/21/18 – Clinical Guidelines for review of Medical Necessity (included as a link in the 6/26/18
bulletin)
6/26/18 – Behavioral Health Review, Provider Bulletin
Qualis Healthcare, Inc. Training Sessions
9/18/17
10/5/17 (BH specific)
10/12/17 (BH specific)
11/2/17 (BH specific)
7/23/18 – Technical assistance on review guidelines
7/26/18 – Technical assistance on review guidelines
7/27/18 – Technical assistance on review guidelines
One-to-one one provider technical assistance via phone and email between provider staff (Rod,
Galin and Maureen) and Qualis Staff (Teresa Kirn, RN and Lisa Layne)
Websites and Online Training Available
WY Medicaid Provider Website - https://wymedicaid.portal.conduent.com/provider_home.html
Qualis Website and Training Videos –
http://www.qualishealth.org/healthcare-professionals/wyoming-medicaid/provider-education
Registering for the Qualis Health Provider Portal – 9/18/17
Requesting an Outpatient Behavioral Health Review – 10/5/17
Requesting an Outpatient Behavioral Health Review – 10/12/17
Q&A for Outpatient Behavioral Health and Therapy Review – 11/2/17
Behavioral Health Review Guidelines – 7/23/18, 7/26/18, 7/27/18
UTILIZATION REVIEW PROCESS, RECONSIDERATION AND APPEALS
Prior authorization appeal processes are outlined in the provider manual
https://wymedicaid.portal.conduent.com/manuals/Manual_CMS1500_7_1_18_Update.pdf
Page 215
Qualis Health reviews each request in accordance with its standard process, including a first
level review performed by a nurse reviewer using decision support criteria contained in a software
product called InterQual. For any requests not approved by the first level reviewer, a second level
review is completed by a physician (for medical services) or a psychiatrist (for behavioral health
services). Based on the psychiatrist’s training, credentialing, experience and WY Medicaid coverage
criteria, the documentation submitted is reviewed to evaluate the clinical and therapeutic
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appropriateness (in amount, duration and scope) of the services being requested. If the second level
review upholds the initial denial, a letter is generated and the provider is notified of the denial/partial
denial.
Providers are instructed regarding how to request a reconsideration if they disagree with the
initial determination. At times, providers have additional clinical history, medical records or treatment
data to support the services requested, but that documentation may have been omitted in the initial
submission. When a provider requests a reconsideration, the same review process is followed, but the
case is submitted to different clinicians (peer reviewer with the same licensure and credentialing) for
review.
If the reconsideration upholds the initial denial, the provider then has the opportunity to
request an appeal to the State. In this process, Qualis will forward all documentation received as part of
the prior authorization request to the State. The case will then be reviewed by internal clinicians on
staff with WY Medicaid.
If a State level appeal upholds the original denial, the provider may make alternate payment
arrangements with the client for the continuation of the denied services (or units), or the client may
submit a formal request to WY Medicaid for an administrative hearing to challenge the denial (or
reduction) in the coverage of services. Administrative hearings are most commonly handled through
the Office of Administrative Hearings, but may be facilitated through other options. In every instance of
a denial, instructions are included regarding the appeal process.
WY MEDICAID RESPONSE TO 10/5/18 JOINT COMMITTEE ON LABOR, HEALTH AND
SOCIAL SERVICES TESTIMONY BY MR. PAUL DEMPLE
Page 9 of 23 – “Medicaid changes over the past 12 months”
“1. Implementation of the 20 cap limit for behavioral health services”
State Response: There was a WY Medicaid benefit administration change proposed, approved and
implemented for the various reasons outlined previously. Public notice of the planned change was
posted in March of 2016, and the program received no comments at that time. Additionally, public
comment periods were also facilitated with the subsequent changes to Chapter 13 of Medicaid rule,
codifying the change in benefit administration. No public comment was received.
“2. Implementation of restrictive service guidelines”
State Response: WY Medicaid program criteria for coverage of behavioral health services has not
changed. The “Guidelines” document is a technical assistance document produced at the request of
several provider groups who sought additional insight in to the types of clinical conditions, baseline
treatment approaches and criteria Qualis Health clinicians were using to guide their initial review of
documentation submitted. It was expressly clarified that the guidelines were not being used to enforce
limitations on requested services or otherwise restrict the provision of medically necessary services
required in excess of what was outlined within the document. The document was simply intended to
provide transparency in the review process, and provide more clinical information regarding the
“baseline” of Qualis Health’s reviews.
3. “Rehabilitation vs. Habilitation”
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State Response: WY Medicaid program criteria for coverage of behavioral health services has not
changed, nor have the definitions of allowable services. Chapter 13 of Medicaid Rule was recently
updated to include the definitions of these terms, which had previously only existed in the provider
billing manuals. The Substance Abuse and Mental Health Services Administration (SAMHSA) compiled a
released a guidance document entitled “Medicaid Handbook” Interface with Behavioral Health Services”
(https://www.nasmhpd.org/sites/default/files/Medicaid-Handbook-Interface-with-Behavioral-Health-
Services%281%29.pdf). This document outlines the various authorities and mechanisms state Medicaid
programs use to cover behavioral health services. WY Medicaid also uses the state plan rehab option to
seek authority for coverage and payment. Medicaid law makes an important distinction between
rehabilitative services and habilitative services. Services provided through the rehabilitative option
must “involve the treatment or remediation of a condition that results in an individual’s loss of
functioning.” Habilitative services are services designed to assist individuals in acquiring, retaining, and
improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and
community-based settings. For clients over the age of 21, habilitative services may only be provided
through a home and community-based waiver.1 While the terminology used in WY Medicaid definitions
has been drafted to be applicable to a broader array of associated services (not just behavioral health),
WY Medicaid staff and Qualis Health are using the appropriate federal definitions within the context of
the work being done. As a note, the distinction between rehabilitative and habilitative services does not
apply to services provided to children under the age of 21. Federal regulations included in the Early and
Periodic Screening, Diagnostic and Treatment program preclude Medicaid denial based on the premise
that a service is habilitative in nature.
Page 12 of 23 –“Recommendations”, #1, #2, #3 and #4 –
State Response: Based on the level of inappropriate claiming and billing identified within the
behavioral health service line, suspending the current prior authorization review process jeopardizes
WY Medicaid’s ability to ensure services being reimbursed are allowable and meet all federal and state
rules and regulations. Should the suspension of current activities be mandated, WY Medicaid would
request consideration for an additional appropriation to cover the immediate increase in program
expenditures as well as additional staffing resources to facilitate the increased workload of the program
integrity unit. The WY Medicaid program integrity unit, upon this change in benefit administration,
would become responsible for requesting medical records, auditing and following through with post-
payment recoveries for all providers of behavioral health services. Historically, providers have been
more amenable to working with the program through a prior authorization process to ensure service
compliance up front rather than be required to return what can potentially be a large sum of money
upon identification of a billing, service or documentation error.
Page 12 of 23 – “Recommendations”, #5 and #6
State Response: These recommendations are outside the scope of the WY Medicaid program. Defer to
the Division of Behavioral Health for follow up.
Page 12 of 23 –“Recommendations”, #7 –
State Response: This recommendation has been addressed – see response to #3 on page 12.
Page 12 of 23 – “Recommendations”, #8 –
1 https://www.nasmhpd.org/sites/default/files/Medicaid-Handbook-Interface-with-Behavioral-Health-
Services%281%29.pdf, page 3-4
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State Response: The WY Medicaid program, with appropriate authority and funding, could seek
coverage of habilitative services for adults with serious and persistent mental illness in a number of
different ways. The two most notable would be an adult mental health waiver, or the submission and
approval of the 1915 (i) state plan option (used by many states to construct a comprehensive support
program for adults with a mental illness. Under this state plan option, the state has authority to specify
target criteria. Qualifying individuals would become eligible for both acute care medical services as well
as long-term support services such as respite, case management, supported employment and
environmental modifications in a home and community based setting. Habilitative service coverage
would also be permitted. The 1915 (i) state plan option may be an option to address this need without a
formal waiver program. The various federal requirements of the 1915 (i) state plan option may be found
at https://www.medicaid.gov/medicaid/hcbs/authorities/1915-i/index.html.
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Appendix Attachments include:
1) 2017 Provider Workshop Bulletin
2) 2018 Provider Workshop Bulletin (4/25/18)
3) Behavioral Health Prior Authorization Bulletin 2/2/2018
4) Behavioral Health Review Bulletin 6/26/18
5) Behavioral Health Services (web notice) 11/15/16
6) 2018 Provider Workshops, RA Banner 4/25/18
7) Chapter 13, Medicaid Rule
8) Clinical Assessment Bulletin 2/26/18
9) Consolidated Codes Bulletin 7/10/17
10) Discontinuing of the MH & SA Option Manual Bulletin 3/3/17
11) Documentation Standards and Rehab-Hab Bulletin 7//8/16
12) Guidelines for WY Medicaid Outpatient Behavioral Health Reviews 6/21/18
13) CMS 1500 Provider Manual
14) Policy Change Regarding OT, PT, ST and BH Services Bulletin 8/28/17
15) Provider Workshop Medicaid Updates PP Slide Deck 2017
16) Provider Workshop PS Unit Policy Updates PP Slide Deck 2017
17) Public Notice – State Plan for Implementation of PA and ABA Services 3/2/16
18) State Plan Amendment 2016
19) Targeted Case Management Bulletin 5/22/17
20) Updated Provider Workshop Bulletin 2018 5/21/18
21) Wyoming Psychological Association Policy Training PP Slide Deck 5/20/18
22) WY Medicaid Webinar PP Slide Deck 10/12/17