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Serving Wyoming Medicaid Providers

 

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Wyoming Medicaid - Claim Forms

 

NPI Updated Forms    

 

Dental Claim (489 K)

 

UB-04 Claim (1.39MB)

 

CMS-1500 (02-12)

 

 

 

Wyoming Medicaid - Enrollment/Agreement Forms

  Provider Enrollment Application
  Letter of Attestation
  Taxpayer ID# Request / WOLFS-109a Form - for New Providers Only
  WOLFS-109b Form - for Updates to existing Provider Information

 

Wyoming Medicaid - EDI Applications

 

Wyoming Medicaid Clearinghouse Authorizations Form - This form is to be completed by providers wishing to authorize/join a clearinghouse or billing agent.

 

Wyoming Medicaid Clearinghouse Applications - This form is for Clearinghouses, Software Vendors or Billing Agents who need to enroll with Wyoming Medicaid to provider electronic services to providers. Electronic services include web portal access, submission of transactions, and receiving 835 files. This form can also be used to make changes to an already enrolled trading partner.

 

EDI Enrollment Application and Agreement - Providers that need to enroll with Wyoming Medicaid for Electronic services, including web portal access, submission of transactions and receiving 835 files need to complete this form. It can also be used to make changes to an already enrolled trading partner.

 

Wyoming Medicaid - Extraordinary Care

 

Nursing Facility Extraordinary Care (208K)

 

Wyoming Medicaid - Miscellaneous Forms

 

 

 

All Providers
Attachment Control Document (36 K)
Adjustment/Void Form (118 K)
Adjustment/Void Form Instructions(24K)
Medical Necessity (7 K
Prior Authorization Request - Non-DME (12 KB)
Prior Authorization Non-DME - Instructions(23 K
Remittance Advice Request Form
Report of Suspected Abuse
Third Party Resources Information (14K

CMS Forms
Abortion Certification (5 K
CAP Limit Waiver Request Form (11KB)
Cap Limit Instructions
Hysterectomy Consent (6 K
LTC Waiver Plan of Care C-501A (24 K)
LTC/HCBS Waiver Plan of Care C-501B (23K
LTC Assisted Living Waiver Plan of Care C-501C
LTC Waiver Plan of Care - self-directed (89 K)
Parenteral Nutrition Necessity (10 K)
Sterilization Consent (16 K
Wyoming Medicaid Client Death Report Form (15KB)

Dental Forms
Dental Provider Client Acceptance Form Updated
Malocclusion Referral Form for Clients under 12
Malocclusion Treatment Request Form
Orthodontic Parent Handout


DME Forms
DME Mileage Verification (22K)Updated
Electric Breast Pump CMN (22K)
KePRO WYDOH DME PA FAX FORM
Wheelchair Necessity (13 K

Institutional Forms
Abortion Certification (5 K
Attestation For Admission Date Form
CAP Limit Waiver Request Form (11KB)
Cap Limit Instructions
Home Health Exemption Letter (95KB
Hysterectomy Consent (6 K
LT-101 Consent Form
LT-101 Consent Form Letter
LT-101 Referral Form
LT-101 Referral Process Physicians Assistants and Nurse Practicioners
LT-101 Referral Process Facilites and Hospitals
LT-101 Request Form
Order Form (45K)
Sterilization Consent (16 K)
WY Department of Health Swing Bed Exemption (96KB)
WY PASRR Informed Consent 02/18/2010 (36K)

 

Wyoming Medicaid - Well Child Visit Forms

 

4 Weeks (36 K)
2 Months (36 K)
4 Months (36 K)
6 Months (35 K)

9 Months (36 K)
1 Year (35 K)
15 Months (35 K)
18 Months (35 K)

2 Years (36 K)
3-4 Years (36 K)
5 Years (36 K)
6-10 Years (42 K)

11-14 Years (42 K)
15-17 years (42 K)
18-20 Years (41 K)

 

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