Insurance Claim Denial External Review Process

Medical Necessity Claim Denial External Review - Overview

Wyoming external review law for insurance claims denied as not medically necessary or on a similar basis will be effective for all covered plans issued or renewed on or after July 1, 2010 pursuant to W.S. 26-40-201 and Wyoming Insurance Department Regulations, Chapter 63.

External review is only available for insurance 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 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 any insurance policy may request an external review of their denied claim if the insurance company based the denial on “medical necessity.”

External Review for Claim Denials for Consumers

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

You must first exhaust all levels of internal appeals or grievances
with your insurance carrier before you can apply for an external review. No later than 120 days from the date of the insurance 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.  Submitting the external review request form does not guarantee your claim will meet eligibility requirements.

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 IROs licensed with the Department of Insurance are independent from insurance carriers. Your insurance carrier will pay the cost of the review. The IRO’s decision is binding on the insurance 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, send 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 insurance carriers are subject to Wyoming Statute, Title 26, Chapter 40, Section 201.  "Insurance carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that transacts the business of insurance as defined by W.S. §26-1-102(a)(xv).

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 Amanda Tarr of the Wyoming Insurance Department at (307) 777-2447 or by email to Amanda Tarr at on our contact us page and note the selection and insured's name so that the rotation process may continue.

The next IRO to be used is in bold print.

National Medical Reviews, Inc
607 Louis Drive, Suite C
Warminster, PA 18974
Phone: 800-283-8196/212-352-7800
Fax: 215-352-7801

Claims Eval, Inc.
4980 Rocklin Road
Rocklin, CA 95677
Phone: 888-962-5246
Fax: 480-393-5620

Advanced Medical Reviews
AMR Account Services Department
600 Corporate Pointe, Suite 300
Culver City, CA 90230
Phone: 800-726-1207 Option 1
Fax: 310-907-9574

Independent Medical Expert Consulting Services, Inc. (IMEDECS)
2060 Detwiler Rd, Suite 100
Harleysville, PA 19438
Phone: 877-782-6331 / 215-855-4633
Fax: 215-855-5318

Federal Hearings and Appeals Services, Inc.
117 West Main Street
Plymouth, PA 18651
Phone: 800-664-7177 / 570-779-5122
Fax: 570-719-0306

MCMC Services, LLC
1451 Rockville Pike, Suite 440
Rockville, MD 20852
Phone: 888-313-6267
Fax: 877-286-3571

C2C Innovative Solutions, Inc.
301 West Bay Street, 6th Floor
Jacksonville, FL 32202
Phone: 833-800-9968/904-394-4701
Fax: 904-224-2706

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

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

44090 W 12 Mile Rd
Novi, MI 48377
Phone: 866-516-6676
Fax: 248-262-5954

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

MAXIMUS – State Appeals
3750 Monroe Avenue, Suite 705
Pittsford, New York 14534
Phone: 888-866-6205
Fax: 585-425-5296
To become an Independent Review Organization, please use the following application Application for Registration as an Independent Review Organization

Wyoming Disability Insurance External Review Law

Pursuant to Wyoming Statute §26-40-201 an insurance 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.

Insurers Role in External Review Process Summary

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

If you would like to review the applicable regulation, click here.