044-63 Wyo. Code R. § 63-9

Current through April 27, 2019

Section 63-9 - Expedited External Review

(a) A claimant or the claimant's authorized representative may make a request for an expedited external review with the commissioner at the time the claimant receives:

• (i) A denial of claim if:
  • (A) The denied claim involves a medical condition of the claimant for which the timeframe for completion of an expedited internal review of a claim denial, if a standard external review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant's ability to regain maximum function; or
  • (B) The claimant's claim concerns a request for an 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; and
  • (C) The claimant or the claimant's authorized representative has filed a request for an expedited review of a claim denial as not being medically necessary or on a similar basis.

(b) The request shall be made in duplicate and include a fee of fifteen dollars ($15.00) payable by check or money order to the Wyoming State Treasurer. For any single claimant, there is an annual limit on fees of seventy-five dollars ($75.00).

• (i) Upon receipt of a request for an expedited external review, the insurer immediately shall send a copy of the request and the fee to the commissioner;

• (ii) Immediately upon receipt of the request pursuant to paragraph (i), the insurance carrier shall determine whether the request meets the reviewability requirements set forth in Section 8(c)(i) through 8(c)(iv) of this Rule. The insurance carrier shall immediately notify the commissioner and the claimant and, if applicable, the claimant's authorized representative of its eligibility determination.

(c) The commissioner may specify the form for the insurer's notice of initial determination under this subsection and any supporting information to be included in the notice.

• (i) The notice of initial determination shall include a statement informing the claimant and, if applicable, the claimant's authorized representative that a insurer's initial determination that an external review request is ineligible for review may be appealed to the commissioner.

(d) The commissioner may determine that a request is eligible for expedited external review notwithstanding an insurance carrier's initial determination that the request is ineligible and require that it be referred for expedited external review.

(e) In making a determination under paragraph (d) 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 this Rule.

(f) Upon determination that the request meets the reviewability requirements, the insurer immediately shall assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to Section 11 of this Rule. The insurer shall immediately notify the commissioner of the name of the assigned independent review organization.

(g) Upon receipt of the request for expedited external review, the insurance carrier or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the denial of claim to the assigned independent review organization electronically or by telephone or facsimile or any other available expeditious method.

(h) As expeditiously as the claimant's medical condition or circumstances require, but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements set forth in Section 8 c)(i) through 8(c)(iv) of this Rule, the assigned independent review organization shall:

• (i) Make a decision to uphold or reverse the denial of claim; and

• (ii) Notify the claimant and, if applicable, the claimant's authorized representative, the insurance carrier, and the commissioner of the decision.

• (iii) The assigned independent review organization is not bound by any decisions or conclusions reached during the insurance carrier's internal review process.

(i) If the notice provided pursuant to paragraph (h) was not in writing, within forty-eight (48) hours after the date of providing that notice, the assigned independent review organization shall:

• (i) Provide written confirmation of the decision to the claimant and, if applicable, the claimant's authorized representative, the insurer, and the commissioner; and

• (ii) Include the information set forth in Section 8(t) of this Rule.

(j) Upon receipt of the notice of a decision pursuant to paragraph (i) reversing the denial of claim, the insurance carrier immediately shall approve the covered benefit that was the subject of the denied claim.

(k) An expedited external review may not be provided for retrospective claim denials.

(l) The assignment by the insurer of an approved independent review organization shall be on the same basis as provided in Section 8(w).

044-63 Wyo. Code R. § 63-9

Amended, Eff. 10/13/2015.