Wyo. Code R. 006-0004-3
Official Group Insurance
Effective Date: 07/01/2001 to 10/19/2001
Rule Type: Superceded Rules & Regulations
Reference Number: 006.0004.3.07012001
For the 120 days the emergency rules are in effect, the following rules shall apply.
The rules in this chapter govern the hearing and adjudication of disputes concerning the allowance and payment of claims and eligibility for coverage. These rules are intended to and shall be construed to provide adjudication in a manner that is as speedy and inexpensive as is consistent with a full and fair hearing and appropriate deliberation.
(a) The rule-making and contested case provisions of the Wyoming Administrative Procedure Act. W.S. §§ 16-3-101 through 16-3-115, as amended, are applicable and are incorporated by reference herein.
(b) Contested case proceedings shall be governed by the Wyoming Rules of Civil Procedure. Rules 6, 11, 16, 26, 28 through 37, (except as the application of these is limited by the terms of W.S. 16-3-107(g), Rule 43, and Rules 45, 46, 55, and 56. The remainder of the Wyoming Rules of Civil Procedure may be referred to by the parties and the hearing officer for guidance.
(c) The Wyoming Rules of Evidence shall not apply to proceedings under these rules, but may be referred to by the parties and the hearing officer for guidance.
(d) In the case of conflict between these rules, the Wyoming Administrative Procedure Act, and the State Employees' and Officials' Group Insurance Act, the statutes shall control.
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 decision of the Director shall be binding in disputes concerning the allowance and payment of claims and eligibility for coverage.
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.
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.
(a) A proceeding under these rules shall be initiated by the filing of a statement of dispute by the complainant. The statement of dispute shall be filed within one (1) year of the date upon which occurred the event forming the basis of the dispute, and 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 to be brought before the Director.
(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.
(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.
Upon receipt of a statement of dispute, the Director shall designate a hearing officer to preside over pre-hearing matters and the hearing. The hearing officer may be an employee of the Department, or an employee of another State agency. Any party may make one request that a different hearing officer be designated, provided the request is made no less than ten (10) days before the date set for the hearing.
If the dispute concerns a matter that the complainant believes is an emergency or is particularly urgent due to the medical condition of a person covered by the Program, the statement of dispute may include a request for expedited proceedings and a conspicuous statement of the circumstances upon which the request is based. The hearing officer shall consider all requests for expedited proceedings, and upon a determination that the circumstances justify expedited proceedings, shall notify the parties. In expedited proceedings the hearing officer may reduce all time intervals provided by these rules.
Once a contested case proceeding is initiated by the filing of a statement of dispute, the hearing officer shall notify the opposing party that a response to the statement of dispute must be filed within fifteen (15) days of the date of the notification. The response shall state the nature and basis of the dispute as it is understood by the responding party, and a brief statement of its reasons for taking the action disputed by the complainant. The response shall state whether the parties have engaged in discussions or attempts to settle the dispute and briefly describe them.
The hearing officer shall set the matter for hearing no later than thirty (30) days from the filing of the response. Notice of the hearing shall be served personally or by sending registered mail to all parties at their last known addresses at least ten (10) days prior to the date set for the hearing. The notice shall contain the information required by W.S. §16-3-107(b). In the hearing officer's discretion, and for good cause shown, the time for hearing may be extended for a period of time not to exceed an additional thirty (30) days.
The parties must request informal discovery prior to filing formal discovery demands authorized by the Wyoming Rules of Civil Procedure. If a party refuses to provide informally requested information or material, the refusing party shall notify the requesting party and the hearing officer within five (5) days of receiving the informal discovery request. The notification shall include an explanation for the refusal. The hearing officer shall liberally grant motions to shorten time for response to formal discovery requests, consistent with reasonable time for parties to provide requested information.
Unless the hearing officer determines that a pre-hearing conference would not be helpful to the parties or the Department, a pre-hearing conferences shall be held. Rule 16 of the Wyoming Rules of Civil Procedure shall apply. The parties shall attempt in good faith at the pre-hearing conference to narrow the issues, limit the amount of evidence, and to resolve the dispute prior to the final hearing. Informal disposition may be made of any matter by stipulation, agreed settlement, consent order or default, pursuant to W.S. § 163-107(n).
(a) Hearings shall be open to the public, except that pre-hearing conferences and hearings may be held by telephone conference call if requested by either party. In addition, the complainant may request in writing that the hearing be closed.
(b) Evidence received during a hearing shall be in the form of relevant sworn testimony subject to cross-examination. Relevant documentary evidence and written testimony may be received as provided in W.S. 16-3-108.
(c) The hearing officer shall cause the entire proceeding, including all testimony, to be recorded on audio tape or such other means as he deems appropriate and consistent with W.S. § 16-3-107(p). A copy of the audio recording any portion of the proceedings shall be provided to a party upon request. A party may, at his own expense, arrange for stenographic recording.
(d) The hearing shall proceed in the following order:
(e) The hearing officer may limit the time allowed for the hearing or any stage thereof.
Within ten (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.
Within ten (10) days of submission of the hearing officer's proposed final order, a party may file an exception to the 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.
Not more than twenty (20) days after the conclusion of the hearing, the Director shall issue his 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 mail.
Any appeal 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.