How are Workers’ Compensation Claims Accepted or Denied in Wyoming?

Compliance Corner

When it comes to accepting or denying claims in Wyoming, state law sets out the rules and procedures for how an acceptance or denial happens and what notice must go along with it. As Simply Research subscribers know, here are the highlights.

The Basics

Upon receipt, the division shall review the initial injury reports to determine if the injury or death resulting from injury is compensable and within the jurisdiction of the Workers' Compensation Act. No subsequent claim for compensation shall be approved if the division determines the injury or death is not compensable and under the jurisdiction of the Workers' Compensation Act or if the employer states on his injury report that the injury is not compensable, until a determination is rendered by the division. The division shall provide notice of its determination to the employee, employer and the claimant.

Steps to Approval or Denial

Following review of each bill and claim for medical and hospital care, the division may approve or deny payment of all or portions of the entire amount claimed and shall:

(i) Notify the employee and the health care provider in writing of any portion of a claim for which the employee may be liable for payment;

(ii) Provide the health care provider with a detailed monthly statement of respective claims and bills for services rendered and the amount approved for payment;

(iii) Provide the employer with a detailed monthly statement of all medical and hospital claims affecting his experience rating.

Determining Benefits

Upon receipt of a claim for impairment, disability or death benefits, and if the initial injury or death resulting from injury is determined compensable, the division shall determine if the injured employee or his dependents are eligible for benefits and shall approve or deny the claim. If a claim is approved, the division shall determine the amount of the award for compensation. The division shall provide notice of any determination to the employer, employee and the claimant.

Procedures

The division shall by rule and regulation establish necessary procedures for the review and settlement of the compensability of an injury or death resulting from injury and of claims through interviews with employees, employers and health care personnel or through review of written reports. Nothing shall prohibit the employer or division from reaching a settlement of up to $2,500 in any case without an admission of compensability or that the injury was work related.

Erroneous Payment

A health care provider receiving payment erroneously pursuant to a determination by the division following review and settlement or a decision by a hearing examiner is liable for repayment to the worker's compensation account. Except in contested cases, the division may deduct the amount liable from future payments limited to deduction of those mistaken payments made for services provided within 12 months before the deduction. If necessary, the division may recover repayment by civil action.

Employer's Failure

No claim for benefits shall be denied based solely on the failure of the employer to have complied with the requirements of the Workers' Compensation Act.

Notice of Denial

If any claim has been approved and for which an employee is receiving benefits is objected to by an employer, the employee shall be notified by the division within one working day of the objection.

Notice to any employee or his dependents of a final determination by the division denying the compensability of an initial injury, a claim for medical or hospital care for which the employee or his dependents may be liable for payment or denying any impairment, disability or death benefit, shall include reasons for denial and a statement of the employee's or his dependents' rights to a hearing before a hearing examiner and to legal representation.

Rules for Determinations

Determinations by the division shall be in accordance with the following:

(i) The initial review of entitlement to benefits shall be made by the division within 15 days after the date the injury report or claim is filed. Following initial review, the division shall issue a final determination or if a final determination cannot be made based upon available information at that time, the division may issue a request for additional information as necessary.

(ii) Following issuance of a request for additional information, the division shall investigate the matter and issue its final determination within 45 days after issuing the request.

(iii) Notice of a final determination issued by the division shall include a statement of reasons and notice of the right to a hearing.

(iv) Any interested party may request a hearing before a hearing examiner on the final determination of the division by filing a written request for hearing with the division within 15 days after the date the notice of the final determination was mailed by the division. If the division has not rendered a final determination within 60 days following the date the claim was filed, any interested party may request a hearing before a hearing examiner. The date a written request for hearing is filed shall be determined pursuant to W.S. 16-4-301(a).

(v) Upon receipt of a request for hearing, the division shall immediately provide notice of the request to the appropriate hearing authority.

(vi) If timely written request for hearing is not filed, the final determination shall not be subject to further administrative or judicial review, provided however that, in its own discretion, the division may, whenever benefits have been denied to a worker, make a redetermination within one year after the date of an original determination regardless of whether or not a party has filed a timely appeal.

Worker's Files

The division shall maintain a complete and current file for every worker's compensation case filed with the division.

Preauthorization

The division pursuant to its rules and regulations may issue a determination of preauthorization for an injured worker's nonemergency hospitalization, surgery or other specific medical care, subject to the following:

(i) The division's determination that the worker suffered a compensable injury is final and not currently subject to contested case or judicial review.

(ii) A claim for preauthorization is filed by a health care provider on behalf of the injured worker.

(iii) Following a final determination to preauthorize, the necessity of the hospitalization, surgery or specific medical care shall not be subject to further review and providers' bills shall be reviewed only for relatedness to the preauthorized care and reasonableness in accord with the division's fee schedules.

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