(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.
