Medical necessity standard-timeline amendments.

Plain English Breakdown

The bill did not pass, so there is no effective date for the changes proposed in the bill.

Medical Necessity Review Time Limits

The bill changes the time limits for health insurers and independent review organizations to decide on the medical necessity of healthcare services.

What This Bill Does

• Changes the number of days a health insurer has to determine the medical necessity of a healthcare service from 45 days to 21 days.
• Requires an independent review organization to make a decision within 21 days after receiving a request for external review.

Who It Names or Affects

• Health insurers who must now decide on medical necessity within 21 days instead of 45 days.
• Independent review organizations that have to make decisions about medical necessity within 21 days after receiving a request.
• Patients and healthcare providers affected by these new time limits.

Terms To Know

Medical Necessity

The requirement for health insurance coverage of services, supplies, or equipment that are needed to diagnose or treat an illness, injury, condition, disease, or symptoms and that meet accepted standards of medicine.

Independent Review Organization (IRO)

A group that reviews decisions made by health insurers about whether a medical service is necessary and can reverse the insurer's decision if it finds the service should be covered.

Limits and Unknowns

• The bill did not pass, so these changes are not currently in effect.
• It does not specify what happens if an organization fails to meet the new time limits.

Current Bill Text

26LSO-0506
2026
STATE OF WYOMING
26LSO-0506
Numbered
2.0

SENATE FILE NO. SF0122

Medical necessity standard-timeline amendments.

Sponsored by: Senator(s) Dockstader and Brennan and Representative(s) Erickson

A BILL

for

AN ACT relating to the insurance code; amending the number of days a health insurer has to determine the medical necessity of a health care service; amending the number of days an independent review organization has to make an external review determination regarding medical necessity of a health care service; and providing for an effective date.

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

Section 1
.

W.S. 26
‑
40
‑
201(d) and (m)(intro) is amended to read:

26
‑
40
‑
201.

Payment of claims under medical necessity standard; review.

(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
not
later than
forty
‑
five (45)
twenty
‑
one (21)
days after receipt of a request for review.

(m)

Within forty
‑
five (45)
Not later than twenty
‑
one (21)
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:

Section 2
.

This act is effective July 1, 2026
.

(END)

1
SF0122