Ch. 30, § 3. General Provisions

(a) The Department shall use the APR DRGs and relative weights developed by 3M Health Information Systems (3M) to assist in reimbursement calculations for inpatient hospital services. The Department shall update the APR DRG software, and update the version of DRGs assigned for reimbursement, as needed. (b) The Department shall calculate reimbursement for all inpatient hospital services for Wyoming Medicaid recipients at participating and non-participating Wyoming Medicaid enrolled hospitals using a prospective per discharge system based-on APR DRGs for acute care services, a per diem-based reimbursement method for rehabilitation services, or a percent of billed charges for transplants, as applicable. (c) The Department shall designate certain services to be reimbursed based on negotiated rates as specialty services. The Department shall notify providers of services that are reimbursed as specialty services. (d) The Department shall distribute additional annual supplemental payments to disproportionate share hospitals pursuant to Wyoming Medicaid State Plan Attachment 4.19A. (e) The Department shall distribute Qualified Rate Adjustment (QRA) payments to qualifying hospitals pursuant to 4.19A, Part 1, Addendum 1 of the Wyoming Medicaid State Plan. (f) The Department shall distribute Private Hospital Supplemental (PHS) payments to qualifying hospitals pursuant to Wyoming Medicaid State Plan Attachment 4.19A, Addendum 3. (g) The Department considers the following services and providers as exempt from APR DRG reimbursement: (i) The Department shall continue to reimburse rehabilitation claims using a per diem payment. (ii) The Department shall reimburse eligible transplant services at a level that covers the provider's eligible costs as calculated using billed charges. The most recently available provider-specific cost-to-charge ratios developed annually by the Department as part of the Department's Medicaid hospital supplemental payment policy calculations will also be used. (iii) The Department may designate certain services to be reimbursed through negotiated rates or through other reimbursement methodologies. (iv) Swing bed services are exempt from the APR DRG methodology. (v) The Department shall not allow acute care hospitals to submit interim claims for APR DRG services. (h) The Department shall require prior authorization for rehabilitation, psychiatric, transplant, and other services determined by the Department.