(a)If any disability insurance policy provides for
settlement of a claim for payment of medical services or
procedures provided by a health care provider using a usual,
customary and reasonable basis the insurer shall:
(i)Submit to the department upon request statistical
data of health care provider's charges on which the insurer
bases payment of claims. Such data shall be submitted upon
request of the commissioner, provided, however, no insurer may
be required to submit data more than once every six (6) months.
The data submitted shall contain only charges for services
performed not more than one (1) year prior to the date of the
most recent data;
(ii)Provide to the claimant, in writing, a complete
explanation of the basis of settlement, if requested by the
claimant in writing, and mai
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(a) If any disability insurance policy provides for
settlement of a claim for payment of medical services or
procedures provided by a health care provider using a usual,
customary and reasonable basis the insurer shall:
(i) Submit to the department upon request statistical
data of health care provider's charges on which the insurer
bases payment of claims. Such data shall be submitted upon
request of the commissioner, provided, however, no insurer may
be required to submit data more than once every six (6) months.
The data submitted shall contain only charges for services
performed not more than one (1) year prior to the date of the
most recent data;
(ii) Provide to the claimant, in writing, a complete
explanation of the basis of settlement, if requested by the
claimant in writing, and maintain the explanation in the claim
file. If the basis of payment is less than the actual charge
made by the health care provider, the explanation shall state
the specific reason for the amount not paid and may not
expressly state that the health care provider is overcharging
unless the allegation is substantiated by fact set out in the
explanation;
(iii) Settle any claim for medical services or
procedures only on the basis of charges made by Wyoming health
care providers of similar qualifications or experience for the
same or similar medical services or procedures if the service or
procedure for which payment is sought was obtained in Wyoming.
However, if the profile or survey does not contain a
statistically credible sample of charges, the insurer may
include in the profile or survey charges from another similar
geographic and demographic area so that a reliable basis is
established.
(b) Statistical data submitted to the department pursuant
to this section shall be confidential in nature and not
available for public inspection.
(c) When a disability insurance policy provides for
settlement of a claim for payment of medical services or
procedures provided by a health care provider using a usual,
customary and reasonable basis or any similar basis:
(i) If the commissioner, based either on a review of
the statistical data submitted pursuant to subsection (a) of
this section or on the receipt of complaints from one (1) or
more insureds, has reason to suspect that a claim or one (1) or
more classes of claims is not being settled on the basis
provided by the policy he may order the company to show cause
why the settlement or settlements should not be changed;
(ii) If the commissioner finds, after notice and
opportunity for hearing, that the company is not settling a
claim or one (1) or more classes of claims on the basis provided
by the policy, he may order a different settlement or
settlements.