§ 27-14-601 — Payment or denial of claim by division; notice; objections; review and settlement of claims; filing fee; preauthorization of hospitalization or surgery

Wyoming § 27-14-601

• Jurisdiction: Wyoming
• Title 27: Labor and Employment
• Ch. 14: WORKER'S COMPENSATION
• Art. 6: CONTESTED CASES

Text

(a) Upon receipt, the division shall review the initial
injury reports to determine if the injury or death resulting
from injury is compensable and within the jurisdiction of this
act. No subsequent claim for compensation under this act shall
be approved if the division determines the injury or death is
not compensable and under the jurisdiction of this act or if the
employer states on his injury report that the injury is not
compensable, until a determination is rendered by the division.
The division shall provide notice of its determination to the
employee, employer and the claimant.
(b) Following review of each bill and claim for medical
and hospital care pursuant to W.S. 27-14-401(b), the division
may approve or deny payment of all or portions of the entire
amount claimed and shall:
(i) Notify the employee and the health care provider
in writing of any portion of a claim for which the employee may
be liable for payment;
(ii) Provide the health care provider with a detailed
monthly statement of respective claims and bills for services
rendered and the amount approved for payment;
(iii) Provide the employer with a detailed monthly
statement of all medical and hospital claims affecting his
experience rating.
(c) Repealed by Laws 1994, ch. 86, § 3.
(d) Upon receipt of a claim for impairment, disability or
death benefits filed under W.S. 27-14-403(g) or 27-14-501(e) and
(f) and if the initial injury or death resulting from injury is
determined compensable and within the jurisdiction of this act,
the division shall determine if the injured employee or his
dependents are eligible for benefits and shall approve or deny
the claim in accordance with this act. If a claim is approved,
the division shall determine the amount of the award for
compensation in accordance with W.S. 27-14-403 through 27-14-406
and 27-14-408, if applicable. The division shall provide notice
of any determination under this subsection to the employer,
employee and the claimant.
(e) In accordance with this act, the division shall by
rule and regulation establish necessary procedures for the
review and settlement of the compensability of an injury or
death resulting from injury and of claims filed under this act
through interviews with employees, employers and health care
personnel or through review of written reports. Nothing in this
act shall prohibit the employer or division from reaching a
settlement of up to two thousand five hundred dollars
($2,500.00) under this subsection in any one (1) case without an
admission of compensability or that the injury was work related.
(f) A health care provider receiving payment erroneously
under this act pursuant to a determination by the division
following review and settlement under subsection (e) of this
section or a decision by a hearing examiner is liable for
repayment to the worker's compensation account. Except in
contested cases, the division may deduct the amount liable from
future payments under this act limited to deduction of those
mistaken payments made for services provided within twelve (12)
months before the deduction. If necessary, the division may
recover repayment by civil action as provided in W.S. 27-14-511.
(g) No claim for benefits under this act shall be denied
based solely on the failure of the employer to have complied
with the requirements of this act.
(h) If any claim under W.S. 27-14-404 through 27-14-406
which has been approved and for which an employee is receiving
benefits is objected to by an employer, the employee shall be
notified by the division within one (1) working day of the
objection.
(j) Notice to any employee or his dependents under this
section of a final determination by the division denying the
compensability of an initial injury, a claim for medical or
hospital care for which the employee or his dependents may be
liable for payment or denying any impairment, disability or
death benefit, shall include reasons for denial and a statement
of the employee's or his dependents' rights to a hearing before
a hearing examiner as provided by this act and to legal
representation.
(k) Determinations by the division pursuant to this
section and W.S. 27-14-605 shall be in accordance with the
following:
(i) The initial review of entitlement to benefits
pursuant to subsections (a) and (e) of this section shall be
made by the division within fifteen (15) days after the date the
injury report or claim is filed. Following initial review, the
division shall issue a final determination or if a final
determination cannot be made based upon available information at
that time, the division may issue a request for additional
information as necessary;
(ii) Following issuance of a request for additional
information under paragraph (k)(i) of this section, the division
shall investigate the matter and issue its final determination
within forty-five (45) days after issuing the request;
(iii) Notice of a final determination issued by the
division under this subsection shall include a statement of
reasons and notice of the right to a hearing;
(iv) Any interested party may request a hearing
before a hearing examiner on the final determination of the
division by filing a written request for hearing with the
division within fifteen (15) days after the date the notice of
the final determination was mailed by the division. If the
division has not rendered a final determination within sixty
(60) days following the date the claim was filed, any interested
party may request a hearing before a hearing examiner in the
manner prescribed by this paragraph. The date a written request
for hearing is filed shall be determined pursuant to W.S.
16-4-301(a);
(v) Upon receipt of a request for hearing, the
division shall immediately provide notice of the request to the
appropriate hearing authority as determined pursuant to W.S.
27-14-616;
(vi) If timely written request for hearing is not
filed, the final determination by the division pursuant to this
subsection shall not be subject to further administrative or
judicial review, provided however that, in its own discretion,
the division may, whenever benefits have been denied to a
worker, make a redetermination within one (1) year after the
date of an original determination regardless of whether or not a
party has filed a timely appeal pursuant to paragraph (iv) of
this subsection.
(m) Repealed by Laws 1996, ch. 82, § 2.
(n) The division shall maintain a complete and current
file for every worker's compensation case filed with the
division in accordance with this act.
(o) The division pursuant to its rules and regulations may
issue a determination of preauthorization for an injured
worker's nonemergency hospitalization, surgery or other specific
medical care, subject to the following:
(i) The division's determination that the worker
suffered a compensable injury is final and not currently subject
to contested case or judicial review;
(ii) A claim for preauthorization is filed by a
health care provider on behalf of the injured worker;
(iii) The division's determination pursuant to this
subsection is issued in accordance with the procedures provided
in subsection (k) of this section;
(iv) Following a final determination to preauthorize,
the necessity of the hospitalization, surgery or specific
medical care shall not be subject to further review and
providers' bills shall be reviewed only for relatedness to the
preauthorized care and reasonableness in accord with the
division's fee schedules.