Wyo. Code R. 007-0001-1
Effective Date: 10/22/2012 to 03/21/2018
Rule Type: Superceded Rules & Regulations
Reference Number: 007.0001.1.10222012
Section 1. Authority. These rules are promulgated by the Adjutant General under the authority given by Wyo. Stat. Ann. § 19-9-403(a).
(a) 'Medical expense' means expenses related to customary treatment by a licensed doctor of medicine, chiropractic or osteopathy, dentist, optometrist, podiatrist, psychologist, physician's assistant, and advance practitioner of nursing acting within the scope of his or her license. Medical expense also includes expenses for prescription medications, surgical or hospital service, medical and surgical supplies, apparatus, essential and adequate artificial replacement, and prosthetics.
(b) 'Reasonable medical expense' means those charges for medical expenses that are necessary and determined reasonable by reference to charges and quantity of services normally allowed by the State of Wyoming's employee group health insurance, Medicare, Medicaid customary charges in the area for similar services, and any other relevant sources related to the particular expense at issue. Reimbursement may be limited to the lowest levels generally accepted by health care providers for providing similar services in the State of Wyoming.
(c) 'State active duty' means that time during which an officer or enlisted man is serving on state active duty orders or traveling to or from any location in relation to performing state active duty.
(a) Prompt reporting is essential to the accurate determination of whether medical expenses are reasonable and are a direct consequence of state active duty.
(b) The occurrence of any medical condition giving rise to a claim under Wyo. Stat. Ann. § 19-9-403(a) shall be reported within the time period below in writing to the Wyoming National Guard Human Resources Office, on a reporting form approved by that office, and contain all information required by the form. The officer or enlisted man (also collectively referred to as 'member') shall file a completed reporting form before the completion of the period of state active duty giving rise to the claim or within forty-eight (48) hours after the time that a reasonable person would have recognized that they had suffered a medical condition potentially covered under Wyo. Stat. Ann. § 19-9-403(a), whichever time period is shorter. Failure to comply with this requirement shall constitute a basis for denying the claim.
(c) At a minimum, the reporting form approved by the Wyoming National Guard Human Resources Office shall include the following, with all information certified to be true by the member:
Section 4. Utilization of Other Payment Sources. Any claim for medical expenses may be denied to the extent that the expense is or was reasonably eligible for payment, coverage or reimbursement from any other source including, but not limited to, other governmental benefits, health insurance, workers' compensation, any other form of insurance or medical payment coverage, or any other entity that may be legally liable for payment of the medical expense at issue. The payment of medical expenses under Wyo. Stat. Ann. § 19-9-403(a) may be denied if coverage from another source was reasonably available, regardless of whether the member has taken the appropriate measures to apply for or require payment from any other party.
(a) In addition to the reporting requirement in Section 3, all claims for reimbursement of reasonable medical expenses shall be submitted to the Wyoming National Guard Human Resources Office within forty-five (45) days of the date that payment is made by the officer or enlisted man seeking reimbursement and shall be sworn to under oath by the member and contain information necessary to determine the amount of reimbursement.
(b) The Human Resources Office shall design a form to facilitate the submission of claims.
(c) All claims shall be accompanied by a treatment report from the medical provider, a copy of any bill for services, medications or supplies, receipt indicating amount paid by the member, documentation of submittal for or payment made by any insurance carrier or third party, and other documentation substantiating the amount of reimbursement for which the member may be eligible.
(a) The Wyoming National Guard Human Resources Office shall be responsible for investigating all claims for medical expense reimbursement under Wyo. Stat. Ann. § 19-9-403(a) and preparing a written decision that shall be sent to the member.
(b) All claims for reimbursement of reasonable medical expenses shall be investigated to the extent necessary to clearly determine whether the claimed medical expense is reasonable, whether the expense is a direct consequence of state active duty, and the extent to which any insurance carrier, other governmental entity or other party may have potential legal liability for payment of the medical expense at issue.
(c) In conducting its investigation, the Human Resources Office may obtain statements from witnesses, review documents, and consult with experts upon matters relevant to a determination of the claim. The member may be required to produce any relevant information. In cases in which the complexity of the matter requires it, the Human Resources Office may request that the Adjutant General appoint an Investigating Officer to conduct an investigation.
(a) While serving in state active duty, officers and enlisted men are entitled to receive reimbursement for reasonable medical expenses paid by the officer or enlisted man as a direct consequence of state active duty. Medical expenses paid by any third party on behalf of the officer or enlisted man shall not be eligible for reimbursement.
(b) Medical expenses are the direct consequence of state active duty if the medical expense is for the treatment of a medical condition that arises out of and in the course of the member's service in state active duty, except that it shall not include medical expenses resulting from medical conditions due to gross negligence, intoxication, or culpable misconduct of the member receiving medical treatment.
(c) Only reasonable medical expenses paid by the officer or enlisted man as a direct consequence of state active duty will be allowed for reimbursement.
(d) Following its investigation, the Human Resources Office shall promptly make its written decision. If the Human Resources Office denies any claim, it shall serve by mail or personal delivery a copy of its written findings and decision to the member and a copy to the Adjutant General, advising the member that he/she has fifteen (15) calendar days from the date the decision was mailed to or personally delivered to the member to request a hearing, in writing, before the Adjutant General. The request shall state the reason and basis for the request and disagreement with the Human Resources Office's decision. If a member fails to request a hearing within fifteen (15) calendar days from service of the Human Resources Office's decision, the Human Resources Office's decision shall become final.
(e) If the member timely requests a hearing, the Adjutant General shall forward the matter to the Office of Administrative Hearings (OAH) to conduct a hearing and provide a recommended decision. Following receipt of the OAH's recommended decision, the Adjutant General shall make the final decision.
(f) The Adjutant General's final decision shall be sent to the member by mail or personal delivery.
Section 8. Reconsideration and Recoupment from Claimant. The Adjutant General may seek recoupment by any lawful means for any payments made by the State of Wyoming pursuant to Wyo. Stat. Ann. § 19-9-403(a) based upon a mistake of law or fact or misrepresentation. Under no circumstances will a decision to allow reimbursement for any claims under Wyo. Stat. Ann. § 19-9-403(a) bind the Adjutant General to pay further or additional claims.