INDEPENDENT MEDICAL CLAIM REVIEW PROCESS

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 provided by your insurance carrier. If you have questions regarding the form sent to you or your denied claim, please contact your insurance carrier. 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 External 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 the receipt of the request.

REGISTERED INDEPENDENT REVIEW ORGANIZATIONS

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 located on the "List" tab in the spreadsheet below. The next IRO to be used can be seen below. Please contact that IRO and notify Amanda Tarr at the Department by email at amanda.tarr@wyo.gov. Please note the company selection and insured's name so that the rotation process may continue.

To become an Independent Review Organization, please use the following application:
Application for Registration as an Independent Review Organization*

IRO Companies

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: Wyoming Insurance Rules, Chapter 63: Medical Necessity Review Rights*