044-63 Wyo. Code R. §§ 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.
Notes
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