044-63 Wyo. Code R. § 63-7

Current through April 27, 2019

Section 63-7 - Exhaustion of Internal Review Process

(a) Except as provided in subsection (d), a request for an external review pursuant to Section 6 of this Rule shall not be made until the claimant has exhausted the insurer's internal review process required by W.S. § 26-40-201(b)(iii).

(b) A claimant shall be considered to have exhausted the insurer's internal review process for purposes of this section, if the claimant or the claimant's authorized representative:

• (i) Has filed a request for internal review involving a denied claim; and

• (ii) Except to the extent the claimant or the claimant's authorized representative requested or agreed to a delay, has not received a written decision on the request for internal review from the insurer within forty five (45) days following the date the claimant or the claimant's authorized representative filed the request for internal review with the insurer.

(c) Notwithstanding paragraph (b), a claimant or the claimant's authorized representative may not make a request for an external review of a denied claim involving a retrospective review determination until the claimant has exhausted the insurance carrier's internal review process.

(d) At the same time a claimant or the claimant's authorized representative files a request for an expedited internal review of a denied claim, the claimant or the claimant's authorized representative may file a request for an expedited external review of the denied claim under Section 9 of this Rule if:

• (i) the claimant has a medical condition where the timeframe for completion of an internal review of the denied claim would seriously jeopardize the life or health of the claimant or would jeopardize the claimant's ability to regain maximum function; or

• (ii) the claimant's claim concerns a request for admission, availability of care, continued stay or health care service for which the claimant received emergency services, but has not been discharged from a health care facility.

(e) Upon receipt of a request for an expedited external review under subparagraph (d) of this section, the independent review organization conducting the external review in accordance with the provisions of Section 9 of this Rule shall determine whether the claimant shall be required to complete the expedited internal review process before it conducts the expedited external review.

• (i) Upon a determination that the claimant must first complete the expedited internal review process the independent review organization immediately shall notify the claimant and, if applicable, the claimant's authorized representative of this determination and that it will not proceed with the expedited external review set forth in Section 9 of this Rule until completion of the expedited internal review process and the expedited internal review process remains unresolved.

(f) A request for an external review of a denied claim may be made before the claimant has exhausted the health carrier's internal review procedures whenever the insurer agrees to waive the exhaustion requirement.

044-63 Wyo. Code R. § 63-7

Amended, Eff. 10/13/2015.