044-63 Wyo. Code R. § 63-8

Current through April 27, 2019

Section 63-8 - Standard External Review

(a) Within one hundred twenty (120) days after the date of receipt of a notice of a denial of claim pursuant to Section 5 of this Rule, a claimant or the claimant's authorized representative may file a request for an external review with the insurer on a form approved by the commissioner.

(b) Within five (5) business days after the date of receipt of a request for external review pursuant to paragraph (a), the insurer shall send a copy of the request to the commissioner together with the fee.

(c) Within five (5) business days following the date of receipt of the external review request from the claimant, the insurer shall complete a preliminary review of the request to determine whether:

(i) The individual is or was a claimant in the insurance policy at the time the health care service was requested or, in the case of a retrospective review, was a claimant in the insurance policy at the time the health care service was provided;

(ii) The health care service that is the subject of the claim denial is a covered service under the claimant's insurance policy, but for a determination by the insurer that the health care service is not covered because it does not meet the requirements for medical necessity or other similar basis;

(iii) The claimant has exhausted the insurer's internal review process unless the claimant is not required to exhaust the insurer's internal review process pursuant to Section 7 of this Rule; and

(iv) The claimant has provided all the information, forms and fee required to process an external review, including the release form provided under Section 5(c) of this Rule.

(d) Within one (1) business day after completion of the preliminary review, the insurer shall notify the commissioner and claimant and, if applicable, the claimant's authorized representative in writing whether:

(i) The request is complete; and

(ii) The request is eligible for external review.

(e) If the request:

(i) Is not complete, the insurer shall inform the claimant and, if applicable, the claimant's authorized representative and the commissioner in writing and include in the notice what information or materials are needed to make the request complete; or

(ii) Is not eligible for external review, the insurer shall inform the claimant and, if applicable, the claimant's authorized representative and the commissioner in writing and include in the notice the reasons for its ineligibility.
- (A) The commissioner may specify the form for the insurer's notice of determination that the request for standard external review is ineligible for review.
- (B) The notice of determination shall include a statement informing the claimant and, if applicable, the claimant's authorized representative of the insurer's determination that the external review request is ineligible for review and may be appealed to the commissioner.

(f) The commissioner may determine that a request is eligible for external review under Section 8 of this Rule notwithstanding a insurer's determination that the request is ineligible and require that it be referred for external review.

(g) In making a determination under subparagraph (f) of this section, the commissioner's decision shall be made in accordance with the terms of the claimant's insurance policy and shall be subject to all applicable provisions of W. S. §§ 26-40-102(a) and 26-40-201.

(h) Whenever the insurance carrier determines that a request is eligible for external review following the preliminary review conducted pursuant to subsection (c), or that the claimant has provided the information requested to make their submission complete as required by paragraph (e)(i) of this section, the carrier shall, within one (1) business day of making such determination:

(i) Assign an independent review organization from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to Section 11 of this Rule to conduct the external review and notify the commissioner of the name of the assigned independent review organization; and

(ii) Notify in writing the claimant and, if applicable, the claimant's authorized representative of the request's eligibility and acceptance for external review.

(i) In reaching a decision, the assigned independent review organization is not bound by any decisions or conclusions reached during the insurer's review process as set forth in the internal review process.

(j) The insurance carrier shall include in the notice that the claimant or the claimant's authorized representative may submit in writing to the assigned independent review organization additional information for consideration by the independent review organization. Such information shall be submitted within five (5) business days following the date of receipt of the notice. Once the assigned independent review organization receives additional information from the claimant, the independent review organization will forward the information to the issuer within one (1) business day of receipt.

(k) Within five (5) business days after the determination by the insurer that the external review request is eligible for external review as identified in paragraph (h) of this section, , the insurance carrier or its designated utilization review organization shall provide to the assigned independent review organization the health information considered in making the claim denial.

(l) Except as provided in paragraph (e), failure by the insurer or its utilization review organization to provide the health information within the time specified in paragraph (k) shall not delay the conduct of the external review.

(m) The independent review organization shall within five (5) days of receipt of the external review request from the insurer determine whether the documentation is complete and immediately notify the claimant and the insurer in writing what information is missing, if any.

(n) The assigned independent review organization shall review all of the information and documents received pursuant to subsection (k) and any other health information submitted in writing to the independent review organization by the claimant or the claimant's authorized representative pursuant to subsection (j).

(o) The insurance carrier may reconsider its denial of the claim at any point prior to the completion of the external review.

(p) Reconsideration by the insurer of its denial of claim determination pursuant to paragraph (o) shall not delay or terminate the external review.

(q) The external review may only be terminated if the insurance carrier decides, upon completion of its reconsideration, to reverse its denial of claim and provide coverage or payment for the health care service that is the subject of the denied claim.

(i) Within one (1) business day after making the decision to reverse its claim denial, as provided in paragraph (q), the insurer shall notify the claimant and, if applicable, the claimant's authorized representative, the assigned independent review organization, and the commissioner in writing of its decision.

(ii) The assigned independent review organization shall terminate the external review upon receipt of the notice from the insurance carrier that the claim denial has been reversed.

(r) In addition to the health information provided pursuant to subsection (k), the assigned independent review organization, to the extent the health information is available and the independent review organization considers them appropriate, shall consider the following in reaching a decision:

(i) The claimant's medical records;

(ii) The attending health care professional's recommendation;

(iii) Consulting reports from appropriate health care professionals and other documents submitted by the insurer, claimant, the claimant's authorized representative, or the claimant's treating provider;

(iv) The terms of coverage under the claimant's insurance policy;

(v) The standards identified in W.S. § 26-40-102(a)(iii).

(vi) All evidence based research used in the insurer's denial of the claim.

(s) Within forty-five (45) days after the date of receipt of the request for an external review, the assigned independent review organization shall provide written notice of its decision to uphold or reverse the denial of claim as medically necessary, to:

(i) The claimant;

(ii) If applicable, the claimant's authorized representative;

(iii) The insurance carrier; and

(iv) The commissioner.

(t) The independent review organization shall include in the notice sent pursuant to paragraph (s):

(i) A general description of the reason for the request for external review;

(ii) The date the independent review organization received the assignment from the insurer to conduct the external review;

(iii) The date the external review was conducted;

(iv) The date of its decision;

(v) The principal reason or reasons for its decision;

(vi) The rationale for its decision; and

(vii) References to the evidence or health information that they considered in reaching their conclusion, including references to how W.S. § 26-40-102 applies to the information reviewed.

(u) Upon receipt of a notice of a decision pursuant to paragraph (s) reversing the denial of claim, the insurance carrier within five (5) business days shall approve the covered benefit that was the subject of the denied claim.

(v) Upon receipt of a notice of decision pursuant to paragraph (s) reversing the denial of a claim, the commissioner shall refund the fee to the claimant.

(w) The assignment by the insurer of an approved independent review organization shall be on a rotational basis established by the commissioner.

044-63 Wyo. Code R. § 63-8

Amended, Eff. 10/13/2015.