Medical Claim Denial External Review Process



Medical Necessity Claim Denial External Review - Overview

Wyoming external review law for disability insurance claim denials will be effective for all covered plans issued or renewed on or after July 1, 2010-- Wyoming Statute, Title 26, Chapter 40, Section 201.

External review is only available for health claims denied for “medical necessity." A covered person must first exhaust the insurer’s internal final appeal process as described in the health insurance contract. After the insurer’s final denial, the covered person or assigned representative may then submit a request to the health insurer for an external review. The external review will be performed by an Independent Review Organization (IRO) that is separate from the insurer and is free of charge for the covered person.

An Independent Review Organization licensed with the Wyoming Department of Insurance will provide external review of denied health claims. The IROs are required to be registered with the Department. Forms and application information are available see links below.

Insurance companies who are authorized to sell disability insurance in the state will be required to provide external review disclosure to their covered persons at the time of the final denial of the claim. Chapter 63 of the Wyoming Insurance Department Regulations describes the full external review process. Language explaining the external review process must be included in the insurance contract. Consumers covered under disability insurance may request an external review of their denied claim if the insurance company based the denial on “medical necessity.”


External Review for Health Claim Denials for Consumers

Your right to an independent external review: Starting July 1, 2010, Wyoming consumers have the right to a review of health claim denial, if the health carrier denied the service, procedure, or supply as "Not Medically Necessary."

You must first exhaust all levels of internal appeals or grievances with your health carrier before you can apply for an external review. No later than 60 days from the date of the health carrier’s final denial and if you have exhausted all levels of appeals, you may submit a written request for an external review to your insurance carrier. You may use Wyoming’s External Review Request Form or the form the company supplies.

If your request qualifies, your insurer will assign your request to an Independent Review Organization (IRO) and notify our department. The IRO will review your medical records and other relevant material received from your health carrier to determine if the health carrier made the correct decision. The IRO’s licensed with the Department of Insurance are independent from the health carriers. Your health carrier will pay the cost of the review. The IRO’s decision is binding on the health carrier.


Standard Review: 
  • The IRO must make a decision within 45 days after it receives a request from the insurer.
Expedited Review: 
  • For an urgent care request, sent the Review Request Form and Certification of Your Treating Physician for expedited consideration of your claim. The IRO must make a decision within 72 hours after the date of receipt of the request.
For more information:

Wyoming Department of Insurance
Attn: External Review
106 E. 6th Avenue
Cheyenne, WY 82001
(307) 777-7401 Fax: (307) 777-2446


Registered Independent Review Organizations (IRO)

All disability carriers are subject to Wyoming Statute, Title 26, Chapter 40, Section 201. Wyoming Statute §26-5-103 defines disability insurance.

Pursuant to Wyoming Regulation Chapter 63, the list of registered Independent Review Organizations (IRO) that can be used in this process is listed below. The next IRO to be used is in bold print. Please select the IRO in bold print and notify Peter Greff of the Wyoming Insurance Department at (307) 777-2448 or by email on our contact us page and note the selection so that the rotation process may continue.


National Medical Reviews, Inc
260 Knowles Ave., Suite 330
Southampton, PA 18966
Phone: 800-283-8196/212-352-7800
Fax: 215-352-7801


Advanced Medical Reviews
AMR Account Services Department
10780 Santa Monica Blvd. #333
Los Angeles, CA 90025
Phone: 800-726-1207 Option 1
Fax: 310-765-6261
states@admere.com



Independent Medical Expert Consulting Services, Inc. (IMEDECS)
100 West Main Street
Suite 310
Lansdale, PA 19446
Phone: 877-782-6331 / 215-855-4633
Fax: 215-855-5318


IMX Medical Management Services, Inc.
1700 Paoli Pike
Malvern, PA
Phone: 800-707-0575 / 484-329-7000
Fax: 484-329-7095


Medwork of Wisconsin, Inc dba Medwork Independent Review
5840 Arndt Rd Ste 2
Eau Claire, WI 54701
Phone: 715-552-0746
Fax: 715-552-0748

MET Healthcare Solutions  1225 North Loop West,
Suite 1055
Houston, TX 77008
Phone: 800-845-8982
Fax: 713-961-7286

 

MAXIMUS Federal Services, Inc.
3130 Kilgore Road, Suite 400
Rancho Cordova, CA 95670
Phone: 800-470-4075 / 703-251-8500
Fax: 703-251-8240


Medical Review Institute of America, Inc.
2875 S. Decker Lake Drive, Suite 300
Salt Lake City, UT 84119
Mailing: P.O. Box 25547
Salt Lake City, UT 84125
Phone: 800-654-2422
Fax: 801-261-3189


IPRO
1979 Marcus Avenue
Lake Success, NY 11042
Phone: 1-800-852-3685 / 516-326-7767
Fax: 516-326-1034


Prest & Associates, Inc
401 Charmany Drive, Suite 305
Madison, WI 53719
Phone: 1-800-358-5129
Fax: 608-232-9929
* Not for use by CIGNA, United Behavioral Health/OptumHealth, Value Options, Inc*


H. H. C. Group
438 North Frederick Avenue
Suite 200A
Gaithersburg, MD 20877
Phone: 301-963-0762
Fax:  301-963-9431

Managed Medical Review Organization, Inc.
44090 W 12 Mile Rd
Novi, MI  48377
Phone:  866-516-6676
Fax:  248-262-5954


If you are a company that would like to be an Independent Review Organization, please fill out the application at the following link. Application for Registration as an Independent Review Organization


Wyoming Disability Insurance External Review Law

Pursuant to Wyoming Statute §26-40-201 a disability policy that provides settlement of claim for a medical service, procedure, or supply shall:
  • Define medical necessity as defined in W.S. § 26-40-102 (a) (iii).
  • Make determinations whether a medical service is medically necessary based only upon the factions stated in the definition contained in W.S. § 26-40-102 (a) (iii).
  • Provide internal review and external review procedures in every disability insurance policy
Disclosing all procedures, timelines and requirements.
  • Upon first denial of claim as not being medically necessary, or on another similar basis, the insurer shall provide to the claimant in writing a complete explanation and why the service, procedure, or supplies are not medically necessary. 
A statement in the following, or substantially equivalent language: “We have denied your request for the provision of or payment for a health care service or course of treatment. You have the right to have our decision reviewed by the following procedures outlined in this notice. You also may have the right to an expedited review under circumstances where a delayed review would adversely affect you.”; and

A statement describing a procedure for having the claim denial reviewed by the insurer, including all applicable time limits, requirements and a process for having an expedited review initiated as expeditiously as the claimant’s medical condition or the circumstances require, and in any event within seventy-two (72) hours.

If you would like to review the applicable statute, click on the following link: Wyoming Medical Necessity Statute, Chapter 40, of Wyoming Insurance Code Title 26

If you would like to review the applicable regulation, click on the following link: Wyoming Insurance Regulation, Chapter 63, Medical Necessity Review Rights