Ch. 3, § 10. Prior Authorization

(a) The Department may require prior authorization before provision of certain Medicaid covered services. The failure to obtain prior authorization before providing services precludes Medicaid reimbursement for such services. Prior authorization is not a guarantee of the client's eligibility or a guarantee of Medicaid payment. (b) Before providing services that require prior authorization, the provider shall request such authorization using the forms specified by the Department. (c) The Department shall grant a timely request for prior authorization if the proposed services are: (i) Medically necessary; (ii) Consistent with the diagnosis and treatment of the client's condition; (iii) In accordance with the standards of good medical practice among the provider's peer group; (iv) Required to meet the medical needs of the client and undertaken for reasons other than the convenience of the client and provider; (v) Performed in the most cost effective and appropriate setting required by the client's condition; and, (vi) Meet any additional criteria established by Wyoming Medicaid Rules or the coverage policies of the Department. (d) Upon review, the Department or its designee may request additional information or documentation from the provider as necessary to determine that the above requirements have been met. The provider may request further review of the request for prior authorization following its submission of additional documentation. (e) When the Department denies a request for prior authorization based upon the failure to meet the requirements set forth above, it shall inform the provider of the denial. The Department shall provide written notice to the client of the denial in accordance with Wyoming Medicaid Rules Chapter 4. Only the client has a right to a hearing pursuant to this section.