§ 26-40-201 — Payment of claims under medical necessity standard; review

(a) As used in this section, "medical necessity or other
similar basis" includes, but is not limited to, "medically
necessary," "medically necessary care" and "medically necessary
and appropriate," as defined in W.S. 26-40-102(a)(iii).
(b) If any insurance policy provides for settlement of a
claim for payment of medical services, procedures or supplies
provided by a health care provider using a medical necessity or
other similar basis the insurer shall:
(i) Define medical necessity or other similar basis
as "medical necessity" is defined in this chapter and W.S.
26-40-102(a)(iii);
(ii) Make all determinations whether a medical
service, procedure or supply is medically necessary based only
upon the factors stated in the definition of medical necessity
contained in W.S. 26-40-102(a)(iii);
(iii) Provide internal review and external review
procedures for all denied claims as required in this section and
disclose all procedures, time lines and requirements for such
review procedures in every insurance policy and as otherwise
required in this section.
(c) When any claim for the provision of or payment for
medical services, procedures or supplies is first denied as not
being a medical necessity, or on another similar basis, the
insurer shall provide to the claimant, in writing, a complete
explanation of the basis for the settlement and shall specify
why the services, procedures or supplies requested are not
medically necessary. Such explanation shall also include:
(i) A statement in the following, or substantially
equivalent, language: "We have denied your request for the
provision of or payment for a health care service or course of
treatment. You have the right to have our decision reviewed by
following the procedures outlined in this notice. You also may
have the right to an expedited review under circumstances where
a delayed review would adversely affect you."; and
(ii) A statement describing a procedure for having
the claim denial reviewed by the insurer, including all
applicable time limits, requirements and a process for having a
expedited review initiated as expeditiously as the claimant's
medical condition or circumstances require, and in any event
within seventy-two (72) hours, where:
(A) The timeframe for the completion of a normal
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.
(d) A claimant shall have not less than thirty (30) days
in which to file a request for the review provided in subsection
(c) of this section and such review shall be completed by the
insurer, and a decision delivered to the claimant, no later than
forty-five (45) days after receipt of a request for review.
(e) If a claim for the provision of or payment for medical
services, procedures or supplies is denied on the basis that it
is not a medical necessity, or on other similar basis, after
having been reviewed by the insurer pursuant to subsection (c)
or (d) of this section, the insurer shall provide to the
claimant, in writing, a complete explanation of the basis for
the decision and shall specify why the services, procedures or
supplies requested are not medically necessary. Such
explanation shall also include:
(i) The signed opinion of at least one (1) credited
medical consultant who agrees with the denial and who is not an
employee of the insurer if requested by the claimant;
(ii) A statement in the following, or substantially
equivalent, language: "We have denied your request for the
provision of or payment for a health care service or course of
treatment. You may have the right to have our decision reviewed
by health care professionals who have no association with us and
is not the attending physician or the physician's partner by
following the procedures outlined in this notice. You also may
have the right to an expedited review under circumstances where
a delayed review would adversely affect you."; and
(iii) A statement describing the procedure for having
the denied claim reviewed by an external review organization
pursuant to regulations adopted by the commissioner. The
statement shall include a description of all procedures, time
limits and requirements, including those related to expedited
reviews, which the claimant must follow to obtain an external
review and include a request for external review form and
release of records form approved by the commissioner.
(f) Within one hundred twenty (120) days of receiving the
written explanation required by subsection (e) of this section,
a claimant may request an external review of the decision which
is the subject of the explanation by filing a written request
for such review. The request shall be submitted to the insurer
on a form approved by the commissioner, unless such form was not
provided to the claimant as required by subsection (e) of this
section, in which event any written request for an external
review shall be sufficient.
(g) Upon receiving a request for external review, the
insurer shall:
(i) Immediately send a copy of the request to the
commissioner;
(ii) Assign the request to an independent review
organization that has been approved by the commissioner for a
preliminary review. The insurer shall provide to the
independent review organization all documents and information
upon which the insurer relied in denying all claims under
review. Failure to provide the documents and other information
shall not delay the conduct of the external review. The
independent review organization shall determine whether:
(A) The claimant is or was a covered person in
the insurance policy at the time the provision of or payment for
medical services, procedures or supplies was requested or
provided;
(B) The provision of or payment for medical
services, procedures or supplies requested by the claimant
reasonably appears to be a covered service under the insurance
policy, but for the determination by the insurer that the
services, procedures or supplies are not a medical necessity;
(C) The insurer has denied the claimant's
request for the provision of or payment for medical services,
procedures or supplies after having been given the opportunity
to review the insurer's first denial one (1) or more times;
(D) The claimant has provided to the insurer all
the information and forms required to process an external
review, including a release form, approved by the commissioner,
by which the claimant authorizes the release of protected health
information pertinent to the external review.
(h) The independent review organization shall within five
(5) days determine whether the documentation is complete and
immediately notify the claimant and the insurer in writing
whether the documentation is complete and, if not, what
information or documentation is missing. The claimant may submit
in writing to the independent review organization any additional
supporting documentation that the independent review
organization should consider or may require when conducting its
external review. If the request for review is not complete, the
independent review organization shall require from the insurer
or the claimant the information or materials needed to make the
request complete.
(j) The independent review organization shall, within one
(1) business day of its receipt, forward all documentation and
information it receives from an insurer or claimant to the
opposing insurer or claimant. The insurer may use any
documentation or other information provided by the claimant to
reconsider its settlement of the claims. If the insurer chooses
to reverse its prior decision, it shall immediately provide
written notice to the claimant, the independent review
organization and the commissioner, at which time the review
shall be terminated.
(k) In addition to the documents and information provided
pursuant to this section, the independent review organization,
to the extent the information is available and the independent
review organization considers them appropriate, shall consider
the following in reaching its 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 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.
(m) Within forty-five (45) days after the date of receipt
of the request for external review, the assigned independent
review organization shall provide written notice to the
claimant, the insurer and the commissioner of its decision to
uphold or reverse the decision of the insurer that the provision
of or payment for medical services, procedures or supplies
requested by the claimant are not medically necessary. Such
written notice shall include:
(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 review;
(iii) The date the external review was conducted;
(iv) The date of its decision;
(v) The principal reasons for its decision;
(vi) The rationale for its decision; and
(vii) References to the evidence or documentation
considered in reaching its decision.
(n) In the event the external review organization
determines the claims should be allowed, the insurer shall
approve the request for the provision of or payment for medical
services, procedures or supplies that was the subject of the
review and notify the claimant of such approval within five (5)
days.
(o) The engagement by an insurer of an independent review
organization to conduct an external review in accordance with
this section shall be fair and impartial. The insurer, insured
and the independent review organization shall comply with
regulations promulgated by the commissioner to ensure fairness
and impartiality in the engagement of approved independent
review organizations, in the terms, termination and payment of
independent review organizations and in the review process.
(p) The commissioner shall adopt regulations establishing
an expedited review by an external review organization 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, and which allows an expedited
external review where:
(i) The timeframe for the completion of a normal
external review would seriously jeopardize the life or health of
the claimant or would jeopardize the claimant's ability to
regain maximum function; or
(ii) 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.
(q) The insurer against whom a request for external review
is filed shall pay the costs of the independent review
organization's external review.
(r) The commissioner shall adopt such regulations as are
necessary to promote the purposes of this section, which
regulations shall include:
(i) Fees, including the waiver of fees for indigent
persons;
(ii) Standards and procedures for the approval of
independent review organizations;
(iii) External review organization reporting and
record retention requirements.
(s) An insurer required to comply with the notification
and appeal procedures of the Employee Retirement Income Security
Act, and being compliant therewith, shall be deemed in
compliance with this section.