INDEPENDENT MEDICAL CLAIM REVIEW PROCESS
EXTERNAL REVIEW FOR CLAIM DENIALS FOR CONSUMERS
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 firstname.lastname@example.org. 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*
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.
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*