Wyo. Code R. 006-0004-3
Official Group Insurance
Effective Date: 01/31/2020 to 06/02/2021
Rule Type: Superceded Rules & Regulations
Reference Number: 006.0004.3.01312020
Section 1. Purpose. The rules in this chapter govern the hearing and adjudication of disputes concerning the allowance and payment of claims and eligibility for coverage and other matters. These rules are intended to and shall be construed to provide adjudication in a speedy and inexpensive manner that is consistent with a full and fair hearing and appropriate deliberation.
Section 2. Incorporation and Applicability of Statutes and Rules. The rule-making and contested case provisions of the Wyoming Administrative Procedure Act. Wyoming Statutes §§ 16-3-101 through 16-3-115, as amended, are applicable and are incorporated by reference herein.
Section 3. 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 decision of the Director shall be binding in disputes concerning the allowance and payment of claims and eligibility for coverage.
Section 4. 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 5. 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.
(a) A proceeding under these rules shall be initiated by the filing of a statement of dispute by the complainant to 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, or within three (3) months of the final notification of denial sent to the employee upon completion of the external review procedure required by the Carrier if applicable and the appeal involved medical judgment or a rescission of coverage. 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 contested case proceedings.
Section 7. Contested Case Hearings. When required, Formal Contested Case Hearings shall be held in accordance with 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 http://rules.wyo.gov. 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; and
(b) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in Section 2(b)(i).
Section 8. Confidentiality of Hearings. Due to the constraints imposed under 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 that the hearing be closed.
Section 9. Proposed Final Order. 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. 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 (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 (5) days of the filing of the exception.
Section 11. Final Order. Not more than forty five (45) days after the conclusion of the hearing, 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. Appeal. 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.