Health insurance-medical necessity reviews.

ORIGINAL
House
Bill No
.
HB0057

ENROLLED ACT NO.
5
,

HOUSE OF REPRESENTATIVES

SIXTY-THIRD LEGISLATURE OF THE STATE OF WYOMING
2015 General Session

AN ACT relating to health insurance plans; amending requirements for review of an insurer's determination that a claimed service, procedure or supply is not medically necessary; and providing for an effective date.

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

Section 1
.

W.S. 26
‑
40
‑
201(
b)
(intro
)
,
(iii), (f), (g)(ii)(A)
,
(B), (j) and (k)(iv)
is
amended to read:

26
‑
40
‑
201
.

Payment of claims under medical necessity standard; review.

(b)

If any
disability
insurance policy
, as defined by W.S. 26
‑
5
‑
103,
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:

(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
disability
insurance policy and as otherwise required in this section.

(f)

Within
sixty (60) days
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:

(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
disability
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
disability
insurance policy, but for the determination by the insurer that the services, procedures or supplies are not a medical necessity;

(j)

All documentation or other information provided to the independent review organization by the insurer or claimant shall also be immediately provided to the adverse party by the independent review organization
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:

(iv)

The
terms of coverage under the claimant's
disability
insurance polic
y
;

Section
2
.

This
act is effective July 1, 201
5
.

(END)

Speaker of the House

President of the Senate

Governor

TIME APPROVED: _________

DATE APPROVED: _________

I hereby certify that this act originated in the House.

Chief Clerk

1