Wyo. Code R. 044-0002-73
General Agency, Board or Commission Rules
Chapter 73: Provider Exemptions for Prior Authorization
Effective Date: 12/03/2025 to Current
Rule Type: Current Rules & Regulations
Reference Number: 044.0002.73.12032025
Section 1. Authority. This Chapter is promulgated by authority of and pursuant to W.S. §§ 26-2-110, 26-5-103, 26-15-110, 16-3-101 through 16-3-106, 26-40-102, 26-40-201, and 26-55-101 et seq.
Section 2. Applicability. This regulation shall not apply to healthcare providers who have not entered into a written agreement with a health insurer or contracted utilization review entity as provided in W.S. § 26-22-503. Out of state providers are ineligible to receive provider exemptions.
Section 3. Definitions. The definitions provided in W.S. §§ 26-55-102 and 26-5-103 shall apply to the interpretation of this regulation.
Section 4. Initial Exemption. Health Insurers or contracted utilization review entities shall establish a procedure to verify a healthcare provider's initial exemption from prior authorization requirements pursuant to W.S. § 26-55-112 on or before March 31, 2026. These procedures shall be made available to the Commissioner upon request.
Section 5. Appeals. Health insurers or contracted utilization review entities shall establish an appeal process in the event a healthcare service is denied for lack of provider exemption from prior authorization requirements or lack of prior authorization. This appeal process language shall be included in all insurance policies and contract forms subject to W.S.§ 26-15-110.
Section 6. Exemption review. Every twelve (12) months a health insurer or contracted utilization entity may review the exemption status of a health care provider. The health care provider shall comply with the review. Failure to comply with the review may be grounds for an exemption to be revoked.
Section 7. Verification of Exemption. When prior authorization is required by a health insurer or contracted utilization review entity, a healthcare provider shall not perform a healthcare service without prior authorization unless the healthcare provider has received confirmation from the health insurer or contracted utilization review entity that the healthcare provider is exempt from prior authorization requirements pursuant to W.S.§ 26-55-112(h).
Section 8. Policy Disclosure Regarding Provider Exemptions from Prior Authorization Requirements. All disability policies delivered or issued for delivery in this state on or after January 1, 2026 shall contain a notice within the policy or contract form stating whether W.S. § 26-55-112 applies.
Section 9. Prior Authorization Requests in Addition to Exemptions. Nothing in W.S. § 26-55-112 or this regulation shall be interpreted to prevent or prohibit a healthcare provider from obtaining a prior authorization from the health insurer or contracted utilization review entity.
Section 10. Payment of Claim Under Medical Necessity Standard. Any adverse determination based on medical necessity as defined by W.S. 26-40-102(a)(iii) resulting from a prior authorization or claim processing error shall be subject to the internal and external review procedures described in W.S. 26-40-201.