26-39-104.

26-39-104.

26-39-103. Spreading of risk.

If any insurer closes a block of business in this state, the insurer shall spread the claims experience of the closed block of business to, for like insureds without regard to individual health problems, other blocks of business still being marketed and sold by that insurer in this state when determining what premiums are to be charged for the contracts included in the closed block of business.

26-39-104. Violations.

Any insurer who violates any provisions of this chapter is subject to denial, suspension or revocation of its certificate of authority as well as the imposition of a penalty as set forth in W.S. 26-1-107.

CHAPTER 40 - HEALTHCARE CLAIMS UNDER SPECIFIED STANDARDS

ARTICLE 1 PAYMENT OF CLAIMS UNDER USUAL, CUSTOMARY AND REASONABLE BASIS

26-40-101. Scope.

This chapter applies to all insurers who solicit or offer for sale in this state individual, group disability or blanket disability policies covering Wyoming residents.

26-40-102. Definitions.

(a) As used in this chapter:

(i) "Health care provider" means any physician, hospital or other person licensed or otherwise authorized in this or another state to furnish to any individual medical or dental care, vision care or hospitalization incident to the furnishing of that care or hospitalization for the purpose of preventing, alleviating, curing or healing human illness, injury or physical disability;

(ii) "Usual, customary and reasonable basis" means the method by which an insurer determines the amount to be paid on a claim for disability benefits by comparing the amount of the claim to amounts charged by other health care providers for the same or similar medical services or procedures;

(iii) "Medical necessity," means:

(A) A medical service, procedure or supply provided for the purpose of preventing, diagnosing or treating an illness, injury, disease or symptom and is a service, procedure or supply that:  (I) Is medically appropriate for the symptoms, diagnosis or treatment of the condition, illness, disease or injury;

(II) Provides for the diagnosis, direct care and treatment of the patient's condition, illness, disease or injury;

(III) Is in accordance with professional, evidence based medicine and recognized standards of good medical practice and care; and

(IV) Is not primarily for the convenience of the patient, physician or other health care provider.

(B) A medical service, procedure or supply shall not be excluded from being a medical necessity under this section solely because the service, procedure or supply is not in common use if the safety and effectiveness of the service, procedure or supply is supported by:

(I) Peer reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE); or

(II) Medical journals recognized by the Secretary of Health and Human Services under Section 1861(t)(2) of the federal Social Security Act.

26-40-103. Payment of claims.

(a) If any disability insurance policy provides for settlement of a claim for payment of medical services or procedures provided by a health care provider using a usual, customary and reasonable basis the insurer shall:

(i) Submit to the department upon request statistical data of health care provider's charges on which the insurer bases payment of claims. Such data shall be submitted upon request of the commissioner, provided, however, no insurer may be required to submit data more than once every six (6) months. The data submitted shall contain only charges for services performed not more than one (1) year prior to the date of the most recent data;

(ii) Provide to the claimant, in writing, a complete explanation of the basis of settlement, if requested by the claimant in writing, and maintain the explanation in the claim file. If the basis of payment is less than the actual charge made by the health care provider, the explanation shall state the specific reason for the amount not paid and may not expressly state that the health care provider is overcharging unless the allegation is substantiated by fact set out in the explanation;

(iii) Settle any claim for medical services or procedures only on the basis of charges made by Wyoming health care providers of similar qualifications or experience for the same or similar medical services or procedures if the service or procedure for which payment is sought was obtained in Wyoming. However, if the profile or survey does not contain a statistically credible sample of charges, the insurer may include in the profile or survey charges from another similar geographic and demographic area so that a reliable basis is established.

(b) Statistical data submitted to the department pursuant to this section shall be confidential in nature and not available for public inspection.

(c) When a disability insurance policy provides for settlement of a claim for payment of medical services or procedures provided by a health care provider using a usual, customary and reasonable basis or any similar basis:

(i) If the commissioner, based either on a review of the statistical data submitted pursuant to subsection (a) of this section or on the receipt of complaints from one (1) or more insureds, has reason to suspect that a claim or one (1) or more classes of claims is not being settled on the basis provided by the policy he may order the company to show cause why the settlement or settlements should not be changed;

(ii) If the commissioner finds, after notice and opportunity for hearing, that the company is not settling a claim or one (1) or more classes of claims on the basis provided by the policy, he may order a different settlement or settlements.  26-40-104. Prohibitions.

(a) No person may make payment on a claim for benefits under an individual, group or blanket disability policy covering residents of this state unless such claim payment is made in compliance with this chapter.

(b) Any person who violates any provisions of this chapter is subject to denial, suspension or revocation of a license or certificate of authority in addition to the imposition of any other penalty provided by W.S. 26-1-107.

ARTICLE 2 MEDICAL NECESSITY STANDARD

26-40-201. Payment of claims under medical necessity standard; review.

(a) As used in this section, "medical necessity or other similar basis" includes, but is not limited to, "medically necessary," "medically necessary care" and "medically necessary and appropriate," as defined in W.S. 26-40-102(a)(iii).

(b) If any insurance policy provides for settlement of a claim for payment of medical services, procedures or supplies provided by a health care provider using a medical necessity or other similar basis the insurer shall:

(i) Define medical necessity or other similar basis as "medical necessity" is defined in this chapter and W.S.