Section 63-5 - Notice of Right to Review (a) An insurance carrier shall notify the claimant in writing of the claimant's right to request a review of any claim denied on the basis of not being medically necessary or on a similar basis. The notice shall include the appropriate statement and information set forth in subsection (b). The notice shall be sent to the claimant each time and at the same time as an insurance carrier sends written notice of the denial of claim on the basis of medical necessity or other similar basis.
(b) The notice of right to review shall include: - (i) Notice of the right to an internal review by the insurer which shall include:
- (A) That the request for an internal review must be filed within thirty (30) days of the date the claimant received the denial of claim;
- (B) That the claimant may submit additional information that relates to the claim;
- (C) That the claimant may request the signed opinion of at least one (1) health care professional who is not an employee of the insurer;
- (D) The procedure for filing the request for internal review; and
- (E) That the claimant may have the right to an expedited review under circumstances where a delayed review would adversely affect the claimant.
- (ii) Notice of the right to an external review by an Independent Review Organization approved by the commissioner which shall include the following or substantially equivalent language:
- (A) "We have denied your request for the provision of or payment for a health care service or course of treatment. After completion of an internal review, you may have the right to have our decision reviewed by health care professionals who have no association with us and are not the attending health care professional or the health care professional's partner by following the procedures outlined in this notice."
- (B) That the request must be made within one hundred twenty (120) days of the receipt of the notice of claim denial following the completion of the internal review;
- (C) That the request for review shall be filed on a form approved by the commissioner and include a health care professional's certification as to medical necessity;
- (D) That the request shall be made in duplicate and include a fee of fifteen dollars ($15.00) payable by check or money order to the Office of the Wyoming State Treasurer.
- (I) The fee may be waived for a claimant whose income is at or below the current federal poverty level guidelines and who files a financial hardship application available upon request from the Wyoming Insurance Department.
- (E) That the insurer shall be responsible for the costs of an external review by an independent review organization; and
- (F) That the claimant may have the right to an expedited review under circumstances where a delayed review would adversely affect the claimant.
- (iii) Notice of the right to an internal and external expedited review which shall include:
- (A) A statement that the expedited review shall be completed as expeditiously as the claimant's medical condition or circumstances require, and in any event within seventy-two (72) hours, where:
- (I) 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
- (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 facility.
- (B) That the request for internal expedited review shall be filed pursuant to the requirements of the insurer. A request for external expedited review must be filed on a form approved by the commissioner and include a health care professional's certification as to medical necessity and of the need for an expedited review.
(c) As part of any notice required by this Rule, the insurer shall include an authorization form, or other document approved by the commissioner that complies with the requirements of 45 CFR Section 164.508, by which the claimant, for purposes of conducting an external review under this Rule, authorizes the insurer and the claimant's treating health care provider to disclose protected health information, including medical records, concerning the claimant that are pertinent to the external review.
044-63 Wyo. Code R. § 63-5
Amended, Eff. 10/13/2015.