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S.F. No. 0095 |
Medical necessity review procedures. |
Sponsored By: Senator(s) Ross, Hastert, Massie, Schiffer and Sessions and Representative(s) Millin and Stubson
AN ACT relating to insurance; defining medical necessity; setting requirements for analyzing insurance coverage and benefit payments under a medical necessity standard; setting requirements for denying payment or coverage; establishing review procedures; modifying unfair claims settlement practices accordingly; allocating costs; and providing for effective dates.
1/13/2009 Bill Number Assigned
1/14/2009 S Received for Introduction
1/15/2009 S Introduced and Referred to S01
1/26/2009 S01 Recommended Amend and Do Pass
ROLL CALL
Ayes: Senator(s) Burns, Decaria, Ross and Sessions
Excused: Senator(s) Perkins
Ayes 4 Nays 0 Excused 1 Absent 0 Conflicts 0
1/26/2009 S Placed on General File
SF0095SS001/ADOPTED
Page 2-line 7 Delete entirely and insert ""medically necessary and appropriate," as defined in W.S. 26-40-102(a)(iii).".
Page 2-lines 8 through 12. Delete.
Page 2-line 21 After "chapter" insert "and W.S. 26-40-102(a)(iii)".
Page 3-line 8 After "." insert "An insurer applying the notification and appeal procedures consistent with the Employee Retirement Income Security Act shall be deemed in compliance with this section.".
Page 4-line 9 Delete "seventy-two (72) hours" insert "three (3) working days".
Page 5-line 3 After "." insert "In the event the insurer applies the provisions of the Employee Retirement Income Security Act related to notification and appeal rights, the insurer will be deemed to have met the provisions of this section.".
Page 5-line 17 Delete "receiving compensation from" insert "an employee of"; after "insurer" insert "if requested by the claimant".
Page 5-line 24 After "us" insert "and is not the attending physician or the physician's partner".
Page 6-line 13 After "." insert "In the event the insurer applies the provisions of the Employee Retirement Income Security Act related to notification and appeal rights, the insurer will be deemed to have met the provisions of this section.".
Page 6-line 23 After "." insert "In the event the insurer applies the provisions of the Employee Retirement Income Security Act related to notification and appeal rights, the insurer will be deemed to have met the provisions of this section.".
Page 8-line 4 After "provided" insert "to the insurer".
Page 8-lines 11 through 23 Delete and insert:
"(h) The independent review organization shall complete the review in a timely manner and immediately notify the claimant and the insurer in writing whether the documentation is complete. The claimant or insurer may submit in writing to the independent review organization any additional supporting documentation that the independent review organization should consider or may require when conducting its external review. If the request for review is not complete, the independent review organization shall require from the insurer or the insured the information or materials needed to make the request complete.".
Page 9-lines 1 through 8 Delete.
Page 9-line 10 After"(j)" delete balance of the line.
Page 9-line 11 Delete.
Page 9-line 12 Delete "accepted for review,"; after "insurer" insert "or insured".
Page 11-line 2 Delete "." insert ";".
Page 11-After line 2 Insert:
"(vi) All evidence based research used in the insurer's denial of the claim.".
Page 12-line 8 After "(o)" delete balance of line.
Page 12-line 9 Delete.
Page 12-line 10 Delete the line through "decision," insert "In the event the external review organization determines the claim should be allowed,".
Page 12-line 15 Delete "assignment" insert "engagement".
Page 12-line 18 After "insurer" insert ", insured".
Page 12-line 20 Delete "assignment" insert "engagement".
Page 14-After line 12 Insert:
"(t) An insurer applying the notification and appeal procedures consistent with the Employee Retirement Income Security Act shall be deemed in compliance with this section.".
Page 15-line 18 Delete "payable" insert "a benefit covered under the terms of the insurance policy.".
Page 15-line 19 Delete.
Page 16-line 18 After ";" insert "and".
Page 16—lines 20 and 21 Delete.
Page 17-lines 1 through 3 Delete.
Page 17-line 5 Delete "(VII)" insert "(IV)".
Page 18-lines 5 through 10 Delete. ROSS, CHAIRMAN
1/27/2009 S Passed CoW
1/28/2009 S Passed 2nd Reading
1/29/2009 S Passed 3rd Reading
ROLL CALL
Ayes: Senator(s) Anderson, J., Bebout, Burns, Case, Coe, Cooper, Decaria, Dockstader, Esquibel, F., Geis, Hastert, Hines, Hunnicutt, Jennings, Johnson, Landen, Larson, Martin, Massie, Meier, Nicholas, Peterson, Ross, Schiffer, Scott, Sessions, Townsend, Vasey and Von Flatern
Nays: Senator(s) Perkins
Ayes 29 Nays 1 Excused 0 Absent 0 Conflicts 0
2/2/2009 H Received for Introduction
2/5/2009 H Introduced and Referred to H01
2/13/2009 H01 Recommended Amend and Do Pass
ROLL CALL
Ayes: Representative(s) Bagby, Barbuto, Cannady, Gingery, Mercer, Patton, Peasley, Quarberg and Throne
Ayes 9 Nays 0 Excused 0 Absent 0 Conflicts 0
2/13/2009 H Placed on General File
SF0095HS001/ADOPTED (TO ENGROSSED COPY)
Page 3-lines 6 through 8 Delete entirely.
Page 4-line 9 Delete "three (3) working days" insert "seventy-two (72) hours".
Page 5-line 3 After "." delete balance of the line.
Page 5-lines 4 through 6 Delete entirely.
Page 5-line 11 Delete "(c)" insert "(d)".
Page 6-line 18 After "." delete balance of the line.
Page 6-lines 19 through 22 Delete entirely.
Page 7-line 9 After "." delete balance of the line.
Page 7-lines 10 through 13 Delete entirely.
Page 9-line 2 Delete "in a timely manner" insert "within five (5) days".
Page 9-line 14 After "(j)" insert "Within seven (7) days after the date of receipt of notice that the independent review organization will conduct the review,".
Page 12-line 17 After "approval" insert "within five (5) days".
Page 14-lines 18 through 21 Delete entirely. GINGERY, CHAIRMAN
SF0095HW001/ADOPTED (TO ENGROSSED COPY)
Page 14-after line 16 Insert:
"(t) An insurer required to comply with the notification and appeal procedures of the Employee Retirement Income Security Act, and being compliant therewith, shall be deemed in compliance with this section.". MERCER, PATTON
2/17/2009 H Passed CoW
SF0095H2001/ADOPTED (TO ENGROSSED COPY)
Page 3-line 10 After "for" insert "the provision of or"; delete "of" insert "for".
Page 5-line 8 After "for" insert "the provision of or payment for".
Page 5-line 11 Delete the standing committee amendment (SF0095HS001/AE) to this line; after "(c)" insert "or (d)".
Page 7-line 23 Delete "to" insert ". The insurer shall provide to the independent review organization all documents and information upon which the insurer relied in denying all claims under review. Failure to provide the documents and other information shall not delay the conduct of the external review. The independent review organization shall".
Page 8-line 2 Before "medical" insert "provision of or payment for".
Page 8-line 3 Delete "were" insert "was".
Page 8-line 6 Before "medical" insert "provision of or payment for".
Page 8-line 7 Delete "appear" insert "appears".
Page 8-line 13 Before "medical" insert "the provision of or payment for".
Page 9-line 2 Delete "complete the review"; before "and" insert "determine whether the documentation is complete".
Page 9-line 4 After "complete" insert "and, if not, what information or documentation is missing"; delete "or insurer".
Page 9-line 10 Delete "insured" insert "claimant".
Page 9-lines 14 through 19 Delete entirely, including the standing committee amendment (SF0095HS001/AE) to these lines.
Page 9-lines 22 through 24 Delete entirely and insert "to the independent review organization by the insurer or claimant shall also be immediately provided to the adverse party by the independent review organization. The insurer may use any documentation or other information provided by the claimant to reconsider its settlement of the".
Page 10-line 1 Delete "claimant's claim" insert "claims".
Page 11-line 13 After "the" insert "provision of or payment for".
Page 11-line 14 Delete "service, procedure or supply" insert "services, procedures or supplies".
Page 11-line 14 Delete "is" insert "are".
Page 12-line 14 Delete "claim" insert "claims".
Page 12-line 15 After "for" insert "the provision of or payment for".
Renumber as necessary. SIMPSON
2/18/2009 H Passed 2nd Reading
SF0095H3001/FAILED (TO ENGROSSED COPY)
SF0095H3001
Page 8-line 7 Delete the Simpson second reading amendment (SF0095H2001/AE) to this line. Further amend as follows: delete "reasonably appear to be" insert "is".
Page 16-line 15 Delete "preventing,".
Page 17-line 7 After ";" delete "and".
Page 17-line 11 Delete "." insert "; and".
Page 17-After line 11 Insert:
"(V) Is not for cosmetic purposes unrelated to illness, disease or injury.".
Page 17-line 17 Delete ":" insert "clinical evidence based medical research by".
Page 17-lines 19 and 20 Delete entirely.
Page 17-line 21 Delete "approved by".
Page 18-line 2 Delete "; or" insert ".".
Page 18-lines 4 through 6. Delete entirely. HALLINAN
2/19/2009 H Passed 3rd Reading
ROLL CALL
Ayes: Representative(s) Anderson, R., Bagby, Barbuto, Berger, Blake, Bonner, Brechtel, Brown, Buchanan, Cannady, Carson, Childers, Cohee, Connolly, Craft, Davison, Diercks, Edmonds, Esquibel, K., Gilmore, Gingery, Goggles, Hales, Hammons, Harshman, Harvey, Illoway, Jaggi, Jorgensen, Landon, Lubnau, Madden, McKim, McOmie, Mercer, Meyer, Miller, Millin, Moniz, Patton, Peasley, Pedersen, Petersen, Philp, Quarberg, Roscoe, Semlek, Shepperson, Simpson, Steward, Stubson, Teeters, Thompson, Throne, Wallis, Zwonitzer, Dn. and Zwonitzer, Dv.
Nays: Representative(s) Hallinan
Excused: Representative(s) Byrd and Lockhart
Ayes 57 Nays 1 Excused 2 Absent 0 Conflicts 0
2/19/2009 S Received for Concurrence
2/24/2009 S Did Concur
ROLL CALL
Ayes: Senator(s) Anderson, J., Bebout, Burns, Case, Coe, Cooper, Decaria, Dockstader, Esquibel, F., Geis, Hastert, Hines, Hunnicutt, Jennings, Johnson, Landen, Larson, Martin, Massie, Meier, Nicholas, Perkins, Peterson, Ross, Schiffer, Scott, Sessions, Townsend, Vasey and Von Flatern
Ayes 30 Nays 0 Excused 0 Absent 0 Conflicts 0
2/24/2009 Assigned Number SEA No. 0035
2/24/2009 S President Signed SEA No. 0035
2/26/2009 H Speaker Signed SEA No. 0035
3/2/2009 Governor Signed SEA No. 0035
3/3/2009 Assigned Chapter Number
Chapter No. 0104 Session Laws of Wyoming 2009.