INDEPENDENT MEDICAL CLAIM REVIEW PROCESS

If your health insurance company has denied a claim because they determine the service or treatment is "Not Medically Necessary," you have the right to an independent, external review. 

This review is conducted by a licensed Independent Review Organization (IRO) that is entirely separate from your insurance company. While there is a standard $15 filing fee for the application (which can be waived for financial hardship), the medical review is free to the consumer. The insurance carrier is legally required to cover the full cost of the review. 

PREREQUISITE: EXHAUST INTERNAL APPEALS

• Before you can request an external review, you must first complete and exhaust all levels of your insurance carrier's internal appeal or grievance processes. 

HOW TO REQUEST AN EXTERNAL REVIEW

1. Watch the Clock: You must submit a written request for an external review to your insurance carrier no later than 120 days from the date of your final denial letter.

2. Use the Required Form: Your insurance carrier must provide you with Wyoming's official External Review Request Form* alongside their final denial notice.

3. The Review Process: If your request qualifies, your insurer will assign your case to a state-licensed IRO and notify the Wyoming Department of Insurance. The IRO will independently review your medical records. The IRO's decision is final and legally binding.

REVIEW TIMELINES

• Standard Review: The IRO must issue a final decision within 45 days of receiving the request from the insurer.

• Expedited/Urgent Review: If a standard delay would seriously jeopardize your life, health, or ability to regain maximum function, you may request an urgent review. To apply for an expedited review, submit the External Review Request Form* along with a completed certificate of your treating physician directly to your insurer. The IRO must issue a decision within 72 hours.

All disability and health insurance carriers operating in Wyoming must strictly comply with W.S. § 26-40-201 and Insurance Department Regulations, Chapter 63. 

Mandatory Requirements:

• Written Disclosure: Upon the first denial of a claim based on lack of medical necessity, you must provide the claimant with a detailed written explanation and clear notice of their external review rights. 

• Mandatory Notice Language: Disclosures must include the exact statutory language (or a department-approved equivalent) confirming the claimant's right to an independent review and expedited consideration. 

• Secure Data Transfer: Carriers must establish and maintain a secure method for transferring sensitive external review requests and medical records to registered IROs. 

• Rotational Assignments: Please email Lauren White at lauren.white1@wyo.gov for the next IRO in the rotation. 

• Insurers' role in the external review process*

An organization wishing to review denied medical claims covered by Wyoming insurance policies must be actively registered with the State. To register with the State or to renew your current registration, please submit an IRO Application*.

Wyoming State Law: W.S. § 26-40-201: Medical Necessity Review Rights ↗

Department Rules: Wyoming Insurance Rules, Chapter 63 ↗