2018 Wyoming Statutes
TITLE 26 - INSURANCE CODE
CHAPTER 40 - HEALTHCARE CLAIMS UNDER SPECIFIED STANDARDS
ARTICLE 1 - PAYMENT OF CLAIMS UNDER USUAL, CUSTOMARY AND REASONABLE BASIS
SECTION 26-40-103 - Payment of claims.
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.
