PRIOR AUTHORIZATION

Yes. Pursuant to W.S. § 26-55-103, health insurers or contracted utilization review entities must make any current prior authorization requirements and restrictions “easily accessible” on its website to enrollees, health care providers and the general public. Additionally, any new or amended prior authorization requirements must be provided in writing to enrollees and affected healthcare providers not less than sixty (60) days before the new or amended requirement is implemented.

If prior authorization is required, the enrollee and the enrollee’s health care provider must be notified of the determination within five (5) calendar days for non urgent and seventy-two (72) hours for urgent requests. An “urgent health care service” is defined as a health care service for which the application of the time periods for making a non-expedited prior authorization decision could, in the opinion of a physician with knowledge of the enrollee’s medical condition either seriously jeopardize the life of health of the enrollee or the ability of the enrollee to regain maximum function or could subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the review. Urgent health care service does include mental and behavioral health care services.

Pursuant to W.S. § 26-55-104, all adverse determinations must be made by a physician or appropriately licensed health care provider. Health care providers reviewing must have sufficient medical knowledge in the applicable area or speciality, knowledge of the coverage criteria and have a current and unrestricted license to practice. The law also requires the reviewing providers to not have any specific conflict of interests such as being employed by or contracted with a health insurer or utilization review entity or having any involvement in the initial adverse determination.

Yes. Pursuant to W.S. § 26-55-105, after issuing an adverse determination, the health insurer or contracted utilization review entity shall provide the opportunity to the health care provider to discuss the medical necessity of the health care service within five (5) business days after the provider’s request.

Maybe. If a prior authorization was received from a previous health insurer or contract utilization review entity and the approved benefit is also available through the new health plan an insurer must honor the prior authorization for not less than ninety (90) days once the new plan commences.

Pursuant to W.S. § 26-55-110, outpatient services and prescription drug authorization periods shall be effective for a period of not less than one (1) year. Inpatient prior authorizations shall be valid for a length of time based on the patient’s clinical condition and cannot be less than one (1) day. Prior authorizations required for health care services that treat chronic or long-term care conditions (does not include prescription of benzodiazepines or schedule II narcotic drugs) shall remain valid for one (1) year.

Yes and no. Pharmaceutical products or services are included in the definition of health care service. However, pharmacy and prescription drugs are specifically excluded from gold carding or prior authorization exemptions. Additionally, pursuant to W.S. § 26-55-111(d) enrolees will not be required to repeat step therapy protocol if they have previously used the prescription drug required by the step therapy protocol, or another prescription drug in the same class with similar efficacy and side effect profile or with the same mechanism of action. The prescribing provider will be required to submit justification and clinical information if requested as to why the covered prescribed drug is needed and documentation of the previously completed step therapy protocols.

Golding carding is a healthcare practice that waives the requirement of prior authorization when healthcare providers meet certain criteria established. Each gold card or exemption is for a specific healthcare service and must be established with each individual insurance company.

Pursuant to W.S. § 26-55-112, to obtain an exemption of prior authorization a health care provider must have requested at least five (5) prior authorization requests within a twelve (12) month period and meet a ninety percent (90%) approval threshold, rounded down to the nearest whole number.

Gold carding will begin January 1, 2026 if a health care provider meets specific requirements. More guidance and specifics related to gold carding will be provided later in 2025.

If you believe a health insurer or contracted utilization review entity is not in compliance with the Wyoming Insurance Code, please File a Complaint ↗.