Wyo. Code R. 006-0004-3
Official Group Insurance
Effective Date: 06/02/2021 to Current
Rule Type: Current Rules & Regulations
Reference Number: 006.0004.3.06022021
Section 1. Authority. The Department is authorized to under Wyoming Statute § 9-3-205(vi) to establish a procedure to hear complaints by insured employees concerning the allowance and payment of claims, eligibility for coverage and other matters.
Section 2. Exclusivity of Remedy. These rules provide the exclusive administrative remedy in disputes concerning the allowance and payment of claims and eligibility for coverage. Pursuant to W.S. § 9-3-205, the Director's decision shall be binding in disputes concerning the allowance and payment of claims and eligibility for coverage.
Section 3. Counsel Not Required. The parties shall have the right to appear in person or by or with counsel but may present their own evidence and argument and shall not be required to have an attorney at any stage of proceedings under these rules.
Section 4. Attorneys' Fees or Costs. The Director has no authority to award attorneys' fees or costs, and shall not consider claims for attorneys' fees or costs. The hearing officer shall not allow the presentation of evidence related to such claims.
Section 5. Medical Necessity Determinations. There is no contested case proceeding for medical necessity determinations. The determination of the independent medical review organization in accordance with W.S. § 26-40-201 shall become the final order of the Director. The date the independent review organization provides its written notice of decision is the date of the Director's final decision for purposes of judicial review of administrative action under Rule 12 of the Wyoming Rules of Appellate Procedure.
Section 6. Initiation of Proceedings. Proceedings other than medical necessity determinations shall be initiated as follows:
(a) The complainant shall file a statement of dispute the Department. The statement of dispute shall be filed within six (6) months of the final notification of denial sent to the employee upon completion of the internal appeals process required by the Carrier. The final notification must be in a written form and may include, but is not limited to, a letter, notification, or explanation of benefits sent to the employee. The statement of dispute shall contain the following:
(i) The complainant's name, address, telephone number, social security number, and place of employment;
(ii) A brief description of the dispute;
(iii) If the dispute involves the denial of coverage or of a claim, the statement shall include the reasons for denial, as understood by the complainant;
(iv) Copies of any relevant documents, including but not limited to bills, statements, and the carrier's explanation of benefits;
(v) Information regarding any contacts the complainant has had with the opposing party regarding the disputed matter, including attempts to settle the dispute; and,
(vi) A statement verifying that a copy of the statement of dispute has been sent to the carrier or other opposing party, and stating the date upon which the copy was sent.
(b) The Department will then forward the statement of dispute to the Office of Administrative Hearings to commence a contested case hearing.
Section 7. Contested Case Hearings. When required, contested case hearings shall be held in accordance with the Wyoming Administrative Procedure Act, W.S. § 16-3-101 through -115 and the rules administered by the Office of Administrative Hearings. The Department hereby incorporates by reference the following uniform rules: Chapter 2 – Uniform Rules for Contested Case Practice and Procedure, adopted by the Office of Administrative Hearings and effective July 20, 2017, found at https://ai.wyo.gov/divisions/human-resources/group-insurance. For these rules incorporated by reference:
(a) The Department has determined that incorporation of the full text in these rules would be cumbersome and inefficient given the length and nature of the rules;
(b) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in Section 8; and
(c) The incorporated rule is maintained at Department and is available for public inspection and copying at cost at the same location.
Section 8. Confidentiality of Hearings. Due to the constraints imposed under the Health Insurance Portability and Accounting Act of 1996 (HIPAA), hearings held under these rules shall be open to the public, except to the extent that statutorily protected confidential health information is presented. Such confidential information shall be sealed by the hearing officer and not released to the public. Additionally, the complainant may request in writing to the hearing officer that the hearing be closed.
Section 9. Proposed Final Order. Within ten business (10) days of the conclusion of the hearing, the hearing officer shall submit a proposed final order, together with the record of the proceedings, to the Director. The proposed final order shall include proposed findings and conclusions. Copies of the proposed final order shall be served on both parties by first class mail.
Section 10. Exceptions to Proposed Final Order, Reply. Within ten business (10) days of submission of the proposed final order to the Director, a party may file an exception to any portion of the proposed final order. The exception shall state the specific portion(s) of the final order the filing party disagrees with, and the reason(s) for the disagreement, and shall propose any alternative finding(s), conclusion(s) or result advocated by the filing party. Any party filing an
exception to the proposed final order submitted to the Director by the hearing officer shall serve a copy of the exception on the other party. A party may file a reply to an exception filed by the opposing party within five business (5) days of the filing of the exception.
Section 11. Final Order. Not more than forty five (45) calendar days after the proposed final order is submitted, the Director shall issue the final decision in the form of a written final order, which shall include findings and conclusions, and shall be served on the parties by certified or registered mail.
Section 12. Judicial Review. Judicial review from a final order of the Director shall be governed by W.S. § 16-3-114 and Rule 12 of the Wyoming Rules of Appellate Procedure.