044-63 Wyo. Code R. § 63-14

Current through April 27, 2019

Section 63-14 - External Review Reporting Requirements

(a) An independent review organization assigned pursuant to Section 8 or

Section 9 of this Rule to conduct an external review shall maintain written records grouped by assigning insurer on all Wyoming requests for external review for which it conducted an external review during a calendar year and, upon request, submit a report to the commissioner, as required under paragraph (b) of this section.

(b) Each independent review organization required to maintain written records on all requests for external review pursuant to paragraph (a) of this section for which it was assigned to conduct an external review shall submit to the commissioner, upon request, a report in the format specified by the commissioner.

(c) The report shall include in the aggregate and for each insurance carrier:

• (i) The total number of requests for external review;

• (ii) The number of requests for external review resolved and, of those resolved, the number resolved upholding the denied claim or final denied claim and the number resolved reversing the denied claim or final denied claim;

• (iii) The average length of time for resolution;

• (iv) A summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the commissioner;

• (v) The number of external reviews pursuant to Section 8 of this Rule that were terminated as the result of a reconsideration by the insurer of its denied claim or final denied claim after the receipt of additional information from the claimant or the claimant's authorized representative; and

• (vi) Any other information the commissioner may request or require.

(d) The independent review organization shall retain the written records required pursuant to this subsection for at least three (3) years.

(e) Each insurer shall maintain written records in the aggregate, and for each type of insurance policy offered by the insurer on all requests for external review that the insurer receives notice of from the insurers pursuant to W.S. § 26-40-201.

(f) Each insurer required to maintain written records on all requests for external review pursuant to paragraph (a) of this section shall submit to the commissioner, upon request, a report in the format specified by the commissioner.

• (i) The report shall include in the aggregate and by type of insurance policy:
  • (A) The total number of requests for external review;
  • (B) From the total number of requests for external review reported under subparagraph (A) of this paragraph, the number of requests determined eligible for a full external review; and
  • (C) Any other information the commissioner may request or require.

(g) The insurer shall retain the written records required pursuant to this subsection for at least five (5) years.

044-63 Wyo. Code R. § 63-14

Amended, Eff. 10/13/2015.