What is external review?
External review is an independent look at certain final denials by a Department of Insurance–registered independent review organization (IRO) that is not your insurance company.
Under W.S. 26-40-201 and Regulation Chapter 63, external review is available when the insurer denied a service, procedure, or supply as not medically necessary or on a similar clinical basis. The IRO decision is generally binding on the insurance carrier. The review is free to you; the carrier pays IRO costs.
General overview: Appeals roadmap. Complete Wyoming internal appeals first unless deemed exhaustion applies.
Who can use Wyoming review?
Wyoming external review under Chapter 63 generally applies when:
- You have DOI-regulated commercial coverage (many HealthCare.gov and fully insured employer plans)
- The denial is based on medical necessity or a similar clinical basis—not pure contractual exclusions, eligibility, or reimbursement-only disputes
- You exhausted internal review—or qualify after 45 days without a final internal decision
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Medicare, Medicaid, and TRICARE
- Products excluded by DOI (check your denial letter)
The insurer assignsyour case to a registered IRO from the Department's rotation list—not a consumer choice process (DOI — IRO program).
Deadlines & exhaustion
120 days (Chapter 63)
Submit a written external review request to your insurance carrier no later than 120 days from the date of the carrier's final internal denial, after exhausting internal appeals.
45-day deemed exhaustion
If you filed a timely internal review and the carrier has not issued a final written decision within 45 days (without your agreement to extend), you may be able to request external review.
30-day internal review deadline
Wyoming regulations require filing internal review within 30 days of a medical-necessity denial notice—do not miss that step.
How to file
- Complete internal review and obtain a final denial with external review rights (or qualify via 45-day rule).
- Send a written external review request to your insurer within 120 days—use the form in your denial packet or the Wyoming External Review Request Form example on the DOI site.
- Include medical records, a physician letter, and—for expedited review—the treating physician's certification of medical necessity and need for expedited review.
- Pay any required filing fee if listed in Chapter 63 (hardship waivers may be available; fee may be refunded if you prevail).
- If the request qualifies, the insurer assigns a registered IRO and notifies the Department of Insurance.
Links hub: Wyoming external appeals links.
How long it takes
- Insurer forwards qualifying requests to an IRO and notifies DOI within 5 business days (Chapter 63)
- Standard external review: IRO decision within 45 days after the IRO receives the request from the insurer
- Expedited external review: within 72 hours after receipt when delay would jeopardize life, health, or ability to regain maximum function, or for certain facility admission/continued-stay situations (Wyo. Ins. Dept. Reg. § 63-9)
- Expedited review generally is not available for purely retrospective claim denials
Is the decision binding?
For qualifying medical-necessity external reviews, the IRO decision is binding on the insurance carrier. If the IRO reverses the denial, the carrier must immediately provide coverage for the service.
Submitting a request does not guarantee the denial meets eligibility requirements—DOI can help if the process stalls.
Medicaid & Medicare
Wyoming Medicaid: Request an administrative fair hearing within 30 days of your eligibility or benefit notice through instructions on the notice and Office of Administrative Hearings—not Chapter 63 commercial IRO review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS; Wyoming SHIP help at Wyoming SHIP (Wyoming Senior Citizens, Inc.).
More: Medicaid managed care · Medicare appeals.