Insurance benefits-usual, customary and reasonable.

WORKING DRAFT
2009
STATE OF
WYOMING
09LSO-0345

HOUSE BILL
NO.
HB0142

Insurance benefits-usual, customary and reasonable.

Sponsored by:
Representative(s) Gilmore and Senator(s) Scott

A BILL

for

AN ACT relating to insurance;
modifying
provisions
for review of claims denied upon
application of usual, customary and reasonable standard;
prohibiting denial of payment for medical charges as specified;
specifying application;
and providing for an effective date.

Be It Enacted by the Legislature of the State of
Wyoming
:

Section 1.
W.S. 26
‑
40
‑
1
03(a)(
i
)
and by creating a new paragraph (iv)
is amended to read:

26
‑
40
‑
103.

Payment of claims.

(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 commissioner shall request such data upon receiving within any three (3) month period two (2)
or more
written complaints from insureds who have been denied payment for the full amount of a health care provider
'
s charge based upon
application of
usual, customary and reasonable criteria
.
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;

(iv)

Not refuse to pay or otherwise deny
a
ny part of a
claim for
payment of
medical services or procedures
provided by a health care provider based upon application of usual, customary and reasonable criteria if the
charge is within one hundred ten percent
(110%)
of the insurer
'
s calculation of the usual, customary and reasonable charge for the service or procedure.

Section 2.
This act applies to
disability
insurance policies
and certificates of coverage
issued, renewed, delivered or issued for delivery in this state on or after July 1, 2009.

Section
3
.
This
act is effective July 1, 2009.

(END)

1
HB0142