§ 26-55-102 — Definitions

(a) As used in this act:
(i) "Adverse determination" means a decision by a
health insurer or contracted utilization review entity to deny,
reduce or terminate benefit coverage for health care services
furnished or proposed to be furnished because the services are
not medically necessary or are experimental or investigational.
A decision to deny, reduce or terminate health care services
that are not covered for reasons other than their medical
necessity or experimental or investigational nature is not an
"adverse determination" for purposes of this act;
(ii) "Authorization" means an approved prior
authorization request;
(iii) "Chronic or long-term care condition" means a
condition that lasts not less than three (3) months and requires
ongoing medical attention, limits activities of daily living or
both;
(iv) "Enrollee" means a person eligible to receive
health care benefits by a health insurer pursuant to a health
plan or other health insurance coverage. The term "enrollee"
includes an enrollee's legally authorized representative;
(v) "Health care service" means health care
procedures, treatments or services provided by a licensed health
care facility or provided by a licensed physician or licensed
health care provider. The term "health care service" also
includes the provision of pharmaceutical products or services
and durable medical equipment;
(vi) "Health insurer or contracted utilization review
entity" means a person or entity that performs prior
authorization for one (1) or more of the following entities:
(A) An employer with employees in Wyoming who
are covered under a health benefit plan, disability insurance as
defined by W.S. 26-5-103 or a health insurance policy;
(B) An insurer that writes health insurance
policies;
(C) A preferred provider organization or health
maintenance organization.
(vii) "Medically necessary health care services"
means as defined by W.S. 26-40-102(a)(iii);
(viii) "Medications for opioid use disorder" means
the use of medications to provide a comprehensive approach to
the treatment of opioid use disorder. United States food and
drug administration approved medications used to treat opioid
addiction include methadone, buprenorphine, alone or in
combination with naloxone, and extended-release injectable
naltrexone;
(ix) "Prior authorization" means the process by which
health insurers or contracted utilization review entities
determine the medical necessity or medical appropriateness of
otherwise covered health care services prior to rendering such
health care services. "Prior authorization" also includes any
health insurer or contracted utilization review entity's
requirement that an enrollee or health care provider notify the
health insurer or contracted utilization review entity prior to
providing a health care service;
(x) "Urgent health care service" means a health care
service for which the application of the time periods for making
a nonexpedited prior authorization decision could, in the
opinion of a physician with knowledge of the enrollee's medical
condition:
(A) Seriously jeopardize the life or health of
the enrollee or the ability of the enrollee to regain maximum
function; or
(B) Could subject the enrollee to severe pain
that cannot be adequately managed without the care or treatment
that is the subject of the review. For purposes of this act,
urgent health care service shall include mental and behavioral
health care services.
(xi) "Step therapy protocol" means an evidence-based
protocol or program that establishes the specific sequence in
which prescription drugs for a specified medical condition are
deemed medically appropriate for a particular patient and are
covered by a health insurer or health benefit plan;
(xii) "Health care provider" means a person licensed,
registered or certified under federal or state laws or
regulations to provide health care services;
(xiii) "This act" means W.S. 26-55-101 through 26-55-
113.