(a) An insurer shall be exempt from the requirements of this chapter, if:
(i) The insurer has annual direct written and unaffiliated assumed premium, including international direct and assumed premium but excluding premiums reinsured with the federal crop insurance corporation and federal flood program, of less than five hundred million dollars ($500,000,000.00); and
(ii) The insurance group of which the insurer is a member has annual direct written and unaffiliated assumed premium including international direct and assumed premium, but excluding premiums reinsured with the federal crop insurance corporation and federal flood program, of less than one billion dollars ($1,000,000,000.00).
(b) If an insurer qualifies for exemption pursuant to paragraph (a)(i) of this section, but the insurance group of which the insurer is a member does not qualify for exemption pursuant to paragraph (a)(ii) of this section, then the ORSA summary report that may be required pursuant to W.S. 26-51-105 shall include every insurer within the insurance group. This requirement may be satisfied by the submission of more than one (1) ORSA summary report for any combination of insurers provided any combination of reports includes every insurer within the insurance group.
(c) If an insurer does not qualify for exemption pursuant to paragraph (a)(i) of this section, but the insurance group of which it is a member qualifies for exemption pursuant to paragraph (a)(ii) of this section, then the only ORSA summary report that may be required pursuant to W.S. 26-51-105 shall be the report applicable to that insurer.
(d) An insurer that does not qualify for exemption pursuant to subsection (a) of this section may apply to the commissioner for a waiver from the requirements of this chapter based upon unique circumstances. In deciding whether to grant the insurer's request for waiver, the commissioner may consider the type and volume of business written, ownership and organizational structure and any other factor the commissioner considers relevant to the insurer or insurance group of which the insurer is a member. If the insurer is part of an insurance group with insurers domiciled in more than one (1) state, the commissioner shall coordinate with the lead state commissioner and with the other domiciliary commissioners in considering whether to grant the insurer's request for a waiver.
(e) Notwithstanding the exemptions stated in this section:
(i) The commissioner may require that an insurer maintain a risk management framework, conduct an ORSA and file an ORSA summary report based on unique circumstances including, but not limited to, the type and volume of business written, ownership and organizational structure, federal agency requests and international supervisor requests;
(ii) The commissioner may require that an insurer maintain a risk management framework, conduct an ORSA and file an ORSA summary report if the insurer has risk-based capital for company action level event as set forth in W.S. 26-48-103 and 26-48-203, meets one (1) or more of the standards of an insurer deemed to be in hazardous financial condition as defined in W.S. 26-3-116, or otherwise exhibits qualities of a troubled insurer as determined by the commissioner.
(f) If an insurer that qualifies for an exemption pursuant to subsection (a) of this section subsequently no longer qualifies for that exemption due to changes in premium as reflected in the insurer's most recent annual statement or in the most recent annual statements of the insurers within the insurance group of which the insurer is a member, the insurer shall have one (1) year following the year the threshold is exceeded to comply with the requirements of this chapter.
(a) The ORSA summary report shall be prepared consistent with the ORSA guidance manual, subject to the requirements of subsection (b) of this section. Documentation and supporting information shall be maintained and made available upon examination or upon request of the commissioner.
(b) The review of the ORSA summary report, and any additional requests for information, shall be made using similar procedures currently used in the analysis and examination of multi-state or global insurers and insurance groups.
(a) Documents, materials or other information, including the ORSA summary report, in the possession of or control of the department that are obtained by, created by or disclosed to the commissioner or any other person under this chapter, is recognized by this state as being proprietary and to contain trade secrets. All such documents, materials or other information shall be confidential by law and privileged, shall not be subject to the Wyoming Public Records Act, shall not be subject to subpoena, and shall not be subject to discovery or admissible in evidence in any private civil action. However, the commissioner is authorized to use the documents, materials or other information in the furtherance of any regulatory or legal action brought as a part of the commissioner's official duties. The commissioner shall not otherwise make the documents, materials or other information public without the prior written consent of the insurer.
(b) Neither the commissioner nor any person who received documents, materials or other ORSA-related information, through examination or otherwise, while acting under the authority of the commissioner or with whom those documents, materials or other information are shared pursuant to this chapter shall be permitted or required to testify in any private civil action concerning any confidential documents, materials or information subject to subsection (a) of this section.
(c) In order to assist in the performance of the commissioner's regulatory duties, the commissioner:
(i) May, upon request, share documents, materials or other ORSA-related information, including the confidential and privileged documents, materials or information subject to subsection (a) of this section, including proprietary and trade secret documents and materials with other state, federal and international financial regulatory agencies, including members of any supervisory college as defined in W.S. 26-44-118, with the NAIC and with any third-party consultants designated by the commissioner, provided that the recipient agrees in writing to maintain the confidentiality and privileged status of the ORSA-related documents, materials or other information and has verified in writing the legal authority to maintain confidentiality; and
(ii) May receive documents, materials or other ORSA-related information, including otherwise confidential and privileged documents, materials or information, including proprietary and trade-secret information or documents, from regulatory officials of other foreign or domestic jurisdictions, including members of any supervisory college as defined in W.S. 26-44-118, and from the NAIC, and shall maintain as confidential or privileged any documents, materials or information received with notice or the understanding that it is confidential or privileged under the laws of the jurisdiction that is the source of the document, material or information;
(iii) Shall enter into a written agreement with the NAIC or a third-party consultant governing sharing and use of information provided pursuant to this chapter, consistent with this subsection that shall:
(A) Specify procedures and protocols regarding the confidentiality and security of information shared with the NAIC or a third-party consultant pursuant to this chapter, including procedures and protocols for sharing by the NAIC with other state regulators from states in which the insurance group has domiciled insurers. The agreement shall provide that the recipient agrees in writing to maintain the confidentiality and privileged status of the ORSA-related documents, materials or other information and has verified in writing the legal authority to maintain confidentiality;
(B) Specify that ownership of information shared with the NAIC or a third-party consultant pursuant to this chapter remains with the commissioner and the NAIC's or a third-party consultant's use of the information is subject to the direction of the commissioner;
(C) Prohibit the NAIC or third-party consultant from storing the information shared pursuant to this chapter in a permanent database after the underlying analysis is completed;
(D) Require prompt notice to be given to an insurer whose confidential information in the possession of the NAIC or a third-party consultant pursuant to this chapter is subject to a request or subpoena to the NAIC or a third-party consultant for disclosure or production;
(E) Require the NAIC or a third-party consultant to consent to intervention by an insurer in any judicial or administrative action in which the NAIC or a third-party consultant may be required to disclose confidential information about the insurer shared with the NAIC or a third-party consultant pursuant to this chapter; and
(F) In the case of an agreement involving a third-party consultant, provide for the insurer's written consent.
(d) The sharing of information and documents by the commissioner pursuant to this chapter shall not constitute a delegation of regulatory authority or rulemaking, and the commissioner is solely responsible for the administration, execution and enforcement of the provisions of this chapter.
(e) No waiver of any applicable privilege or claim of confidentiality in the documents, proprietary and trade-secret materials or other ORSA-related information shall occur as a result of disclosure of such ORSA-related information or documents to the commissioner under this section or as a result of sharing as authorized in this chapter.
(f) Documents, materials or other information in the possession or control of the NAIC or a third-party consultant pursuant to this chapter shall be confidential by law and privileged, shall not be subject to the Wyoming Public Records Act, shall not be subject to subpoena, and shall not be subject to discovery or admissible in evidence in any private civil action.
Any insurer failing, without just cause, to timely file the ORSA summary report as required in this chapter shall be required, after notice and hearing, to pay a penalty of two thousand five hundred dollars ($2,500.00) for each day's delay, to be recovered by the commissioner. The maximum penalty under this section is seventy-five thousand dollars ($75,000.00). The commissioner may reduce the penalty if the insurer demonstrates to the commissioner that the imposition of the penalty would constitute a financial hardship to the insurer.
The requirements of this chapter shall become effective on January 1, 2015. The first filing of the ORSA summary report shall be in 2015 pursuant to W.S. 26-51-105.
26-52-101. Licensure of pharmacy benefit managers.
No person shall act or hold himself out as a pharmacy benefit manager in this state unless he obtains a license from the department. The department shall through rules establish license requirements and procedures for the licensing of pharmacy benefit managers consistent with this article. The requirements shall only provide for the adequate identification of licensees and the payment of the required licensing fee.
(a) As used in this article:
(i) "Claim" means a request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a drug or for providing a medical supply or device;
(ii) "Insurer" means the entity defined in W.S. 26-1-102(a)(xvi) and who provides health insurance coverage in this state;
(iii) "List" means the list of drugs for which a pharmacy benefit manager has established a maximum allowable cost;
(iv) "Maximum allowable cost" means the maximum amount that a pharmacy benefit manager will reimburse a pharmacist or pharmacy for the cost of a generic drug;
(v) "Network providers" means those pharmacies that provide covered health care services or supplies to an insured or a member pursuant to a contract with a network plan to act as a participating provider;
(vi) "Pharmacy" means an entity through which pharmacists or other persons practice pharmacy as specified in W.S. 33-24-124;
(vii) "Pharmacy benefit manager" means an entity that contracts with a pharmacy or the pharmacy's designee who holds a contract with the pharmacy benefit manager on behalf of an insurer or third party administrator to administer or manage prescription drug benefits;
(ix) "Pharmacy services" means any product, good or service, or any combination of products, goods or services, provided as part of the practice of pharmacy;
(x) "Pharmacy services administrative organization" means an organization that evaluates and executes pharmacy benefit manager contracts on behalf of pharmacies and provides administrative, clerical, audit and data analytics support services.
(a) Any pharmacy benefit manager or person acting on behalf of a pharmacy benefit manager who conducts an audit of a pharmacy shall follow the following procedures:
(i) Provide written notice to the pharmacy not less than ten (10) business days before conducting any on-site, initial audit;
(ii) Conduct any audit requiring clinical or professional judgment through or in consultation with a licensed pharmacist;
(iii) Limit the period covered by the audit to not more than two (2) years from the date that an audited claim was adjudicated;
(iv) Allow verifiable statements or records, including medication administration records of a nursing home, assisted living facility, hospital, physician or other authorized practitioner, to validate the pharmacy record;
(v) Allow legal prescriptions, including medication administration records, faxes, electronic prescriptions or documented telephone calls from the prescriber or the prescriber's agent, to validate claims in connection with prescriptions, refills or changes in prescriptions;
(vi) Apply the same standards and parameters to each audited pharmacy as are applied to other similarly situated pharmacies in a pharmacy network contract in this state;
(vii) Not conduct any audit provided for in this section during the first seven (7) calendar days of any month without the consent of the audited pharmacy; and
(viii) Establish a written appeals process and provide a copy to every audited pharmacy.
(b) A pharmacy benefit manager or person acting on behalf of a pharmacy benefit manager who conducts an audit of a pharmacy also shall comply with the following requirements:
(i) Any finding of overpayment or underpayment shall be based on the actual overpayment or underpayment and not on a projection based on the number of patients served having a similar diagnosis or on the number of similar orders or refills for similar drugs;
(ii) Any finding of an overpayment shall not include the dispensing fee amount unless:
(A) A prescription was not received by the patient or the patient's designee;
(B) The prescriber denied authorization;
(C) The prescription dispensed was a medication error by the pharmacy; or
(D) The identified overpayment is based solely on an extra dispensing fee.
(iii) No audit shall use extrapolation in calculating the recoupments or penalties for audits, unless required by state or federal contracts;
(iv) No payment for the performance of an audit shall be based on a percentage of the amount recovered;
(v) Interest shall not accrue during the audit period;
(vi) No audit shall consider any clerical or recordkeeping error, such as a typographical error, scrivener's error or computer error regarding a required document or record, as fraud. These errors may be subject to recoupment. No recovery shall be assessed for errors causing no financial harm to the patient or plan. Errors that are the result of a pharmacy failing to comply with a formal corrective action plan may be subject to recovery. Any recoupment shall be based on the actual overpayment of a claim;
(vii) A preliminary audit report shall be delivered to the audited pharmacy within one hundred twenty (120) days after the conclusion of the audit;
(viii) A pharmacy shall be allowed at least thirty (30) days following receipt of the preliminary audit report to provide documentation addressing any audit finding, and a reasonable extension of time shall be granted upon request;
(ix) A final audit report shall be delivered to the pharmacy not more than one hundred twenty (120) days after the preliminary audit report is received by the pharmacy or submission of final internal appeal, whichever is later;
(x) Recoupment of any disputed funds or repayment of funds to the pharmacy benefit manager or insurer by the pharmacy, if permitted pursuant to contracts, shall occur, to the extent demonstrated or documented in the pharmacy audit findings, after final internal disposition of the audit including the appeals process. If the identified discrepancy for an individual audit exceeds fifteen thousand dollars ($15,000.00), any future payments to the pharmacy may be withheld pending finalization of the audit;
(xi) No chargebacks, recoupment or other penalties may be assessed until the appeal process has been exhausted and the final report issued.
(c) Subsections (a) and (b) of this section shall not apply to:
(i) Audits in which suspected fraudulent activity or other intentional or willful misrepresentation is evidenced by a physical review, review of claims data, statements or other investigative methods; or
(ii) Audits of claims paid for by federally funded programs.
(d) This section shall apply to a contracted pharmacy, or the pharmacy's designee who holds a contract with a pharmacy benefit manager, entered into, renewed or extended on or after July 1, 2016, and to all audits of pharmacies on and after July 1, 2017.
26-52-104. Maximum allowable cost; offering information and alternatives.
(a) To place a drug on a maximum allowable cost list, a pharmacy benefit manager shall ensure that the drug is:
(i) If the drug is a generically equivalent drug, rated "A" or "B" in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book), or rated "NR" or "NA," or has a similar rating, by a nationally recognized reference;
(ii) Generally available for purchase by retail pharmacies in the state from national or regional wholesalers;
(iii) Not obsolete or temporarily unavailable.
(b) In formulating the maximum allowable cost price for a drug, an insurer or pharmacy benefit manager shall consider only the price of that drug and any drug listed as therapeutically equivalent to that drug in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book).
(c) Notwithstanding subsection (b) of this section, if a therapeutically equivalent generic drug is unavailable or has limited market presence, an insurer or pharmacy benefit manager may place on a maximum allowable cost list a drug that has:
(i) A "B" rating in the most recent version of the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations (Orange Book); or
(ii) An "NR" or "NA" rating, or a similar rating, by a nationally recognized reference.
(d) A pharmacy benefit manager shall:
(i) Make available to each network provider at the beginning of the term of the network provider's contract, and upon renewal of the contract, the sources utilized to determine the maximum allowable cost pricing;
(ii) Provide a telephone number, email address and website at which a network pharmacy or the pharmacy's designee who holds a contract with the pharmacy benefit manager may contact an employee of a pharmacy benefit manager to discuss the pharmacy's appeal;
(iii) Provide a process for network providers to readily access the maximum allowable cost applicable to that provider;
(iv) Review and update applicable maximum allowable cost price information at least once every seven (7) business days to reflect any modification of maximum allowable cost pricing; and
(v) Ensure that dispensing fees are not included in the calculation of maximum allowable cost.
(e) A pharmacy benefit manager shall establish a process by which a contracted pharmacy, or the pharmacy's designee who holds a contract with the pharmacy benefit manager, can appeal the provider's reimbursement for a drug subject to maximum allowable cost pricing. A contracted pharmacy, or the pharmacy's designee who holds a contract with the pharmacy benefit manager, shall have up to ten (10) business days after dispensing a drug subject to a maximum allowable cost in which to appeal the amount of the maximum allowable cost. A pharmacy benefit manager shall respond to the appeal within ten (10) business days after the contracted pharmacy or the pharmacy's designee who holds a contract with the pharmacy benefit manager makes the appeal.
(f) If a maximum allowable cost appeal is denied, the pharmacy benefit manager shall provide to the appealing pharmacy, or the pharmacy's designee who holds a contract with the pharmacy benefit manager, the reason for the denial and the national drug code number for the drug that is available for purchase by similarly situated pharmacies in the state and the names of national or regional wholesalers that have the product available for purchase at a price that is at or below the maximum allowable cost.
(g) If an appeal is upheld, the pharmacy benefit manager shall make an adjustment to the applicable maximum allowable cost no later than one (1) day after the date of the determination and make the adjustment applicable to all similarly situated network pharmacy providers, as determined by the insurer or pharmacy benefit manager. The pharmacy benefit manager shall allow the appealing pharmacy to reverse and rebill the claim which was the subject of the appeal.
(h) This section shall apply to a contracted pharmacy, or the pharmacy's designee who holds a contract with a pharmacy benefit manager, entered into, renewed or extended on or after July 1, 2016, and to contracts on and after July 1, 2017.
(j) A pharmacy benefit manager may not, by contract or otherwise, prohibit or penalize a pharmacy or pharmacist for:
(i) Disclosing information to a covered individual regarding any cost differential that the covered individual must pay for a particular prescription under the individual's prescription drug benefit or outside of the individual's prescription drug benefit;
(ii) Offering to a covered individual a more affordable alternative if one is available.
(k) A pharmacy benefit manager shall not prevent a network pharmacy or the pharmacy's designee who holds a contract with the pharmacy benefit manager from filing appeals in an electronic batch format. The pharmacy benefit manager shall respond in an electronic format to valid reimbursement appeals filed in an electronic batch format. A batch appeal shall not be considered a valid appeal unless all required information for each claim in the batch is submitted electronically with the correct, contractually required information and in the required format. An appeal shall not be considered valid for purposes of the ten (10) day response timeframe until all information is received.
(m) A pharmacy or pharmacist may decline to provide pharmacy services to a patient or pharmacy benefit manager if the pharmacy or pharmacist is to be paid less than the pharmacy acquisition cost for the pharmacy providing pharmacy services.
(a) A pharmacy benefit manager or an agent of a pharmacy benefit manager shall not:
(i) Cause or knowingly permit the use of an advertisement, promotion, solicitation, representation, proposal or offer that is untrue, deceptive or misleading;
(ii) Charge a pharmacist or pharmacy provider a fee for any of the following:
(A) The submission of a claim;
(B) Enrollment or participation in a retail pharmacy network;
(C) The development or management of claims processing services or claims payment services related to participation in a retail pharmacy network;
(D) An application to apply for network access with the pharmacy benefit manager;
(E) Credentialing or re-credentialing.
(iii) Retroactively deny or reduce reimbursement for a covered pharmacy service or claim after adjudication of the claim, unless:
(A) The original claim was fraudulent; or
(B) The denial or reduction is necessary to correct errors found in an audit, provided that the audit was conducted in compliance with W.S. 26-52-103.
(vii) Prohibit a pharmacy, pharmacy services administrative organization, contracting agent or agent of a pharmacy from sharing, upon request, copies of pharmacy benefit manager contracts with the department of insurance;
(viii) Prohibit, restrict or limit disclosure of information to the insurance commissioner, law enforcement or other state or federal government officials who are investigating or examining a complaint or conducting a review of the pharmacy benefit manager's compliance with the requirements of this chapter.
(c) Insurers, pharmacies and pharmacy benefit managers shall adhere to all state laws and rules when mailing or shipping prescription drugs into the state.
All contracts between a pharmacy benefits manager and a pharmacy services administrative organization, or its contracted pharmacies, and all contracts directly between a pharmacy benefits manager and a pharmacy shall include a process to investigate and resolve disputes.
W.S. 26-52-104 through 26-52-106 shall apply to all health benefit plan issuers and pharmacy benefit managers except those claims associated with the Wyoming Medicaid fee-for-service program, the Wyoming workers compensation division or those claims otherwise prohibited by federal law.
The following provisions apply to situations where there is a contract between an insurer or the insurer's intermediary and a pharmacy regarding the payment of insurance claims for pharmacy services pursuant to W.S. 26-52-102(a)(ix) submitted to an insurer or the insurer's intermediary.
(a) As used in this chapter:
(i) "Applicable number of calendar days" means:
(A) For claims submitted electronically, twenty-one (21) days;
(B) For claims submitted in a manner other than electronically, thirty (30) days.
(ii) "Clean claim" means a claim that has no defect, including any lack of required substantiating documentation or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this chapter;
(iii) "Insurer" means as defined by W.S. 26-1-102(a)(xvi).
26-52-203. Payment of claims to pharmacy providers.
(a) A contract between an insurer or the insurer's intermediary and a pharmacy for prescription drug coverage offered by the insurer or the insurer's intermediary shall require the insurer or the insurer's intermediary to make payment to the pharmacy for all clean claims submitted by a pharmacy within the applicable number of calendar days after the date that the clean claim is received. For purposes of this section, a claim is considered to have been received:
(i) For claims submitted electronically, on the date that the claim is submitted; or
(ii) For claims submitted in any manner other than electronically, on the fifth day after the postmark date of the claim or the date specified on the time stamp of the transmission of the claim.
(b) For purposes of this section, a contract between an insurer or the insurer's intermediary and a pharmacy regarding prescription drug coverage offered by an insurer or the insurer's intermediary shall include any contract regarding prescription drug coverage offered by the insurer or the insurer's intermediary under which a pharmacy is legally obligated, either directly or through an intermediary such as a pharmacy benefit manager.
(c) If the insurer or the insurer's intermediary does not make payment within the applicable number of calendar days after a clean claim is received, or resubmitted under subsections (e) and (f) of this section, the insurer or the insurer's intermediary shall pay interest to the pharmacy at the rate of eighteen percent (18%) per annum, billed weekly.
(d) A claim shall be considered a clean claim if the insurer or the insurer's intermediary does not provide notice to the pharmacy of any deficiency in the claim within ten (10) days after an electronically submitted claim is received or within fifteen (15) days after a claim that is submitted in any other manner is received.
(e) If an insurer or the insurer's intermediary determines that a claim submitted is not a clean claim, the insurer or the insurer's intermediary shall notify the pharmacy of the determination within ten (10) days of receiving an electronically submitted claim or within fifteen (15) days of receiving a claim that is submitted in any other manner. The notice shall specify all defects in the claim and list all information or documents necessary for the proper processing and payment of the claim.
(f) A claim resubmitted to an insurer or the insurer's intermediary with additional information pursuant to subsection
(e) of this section shall be considered to be a clean claim if the insurer or the insurer's intermediary fails to provide notice to the pharmacy of any defect in the claim within ten (10) days of the date that additional information is received if the claim is resubmitted electronically or within fifteen (15) days of the date that additional information is received if the claim is resubmitted in any other manner. A resubmitted claim that is considered to be a clean claim under this subsection shall be paid within the applicable number of calendar days after the date that the resubmitted claim is received and, if payment is not timely made, interest shall accrue as provided by subsection (c) of this section.
(g) Payment of a clean claim under this section shall be considered to have been made on the date that the payment is transferred to the pharmacy provider account, or to the central pay account of the pharmacy services administrative organization that is directly contracted by the pharmacy, with respect to claims paid electronically and on the date that the payment is submitted to the postal service or common carrier for delivery with respect to claims paid in any other manner.
(h) No insurer shall directly or indirectly charge a pharmacy or hold the pharmacy responsible for fees associated with claims payment.
(a) As used in this chapter:
(i) "Third party administrator" means a person who directly or indirectly underwrites, collects charges, collateral or premiums from, or adjusts or settles claims on residents of this state, in connection with life, annuity, health, or stop-loss coverage offered or provided by an insurer, but does not include any of the following:
(A) An employer on behalf of its employees or the employees of one (1) or more subsidiary or affiliated corporations of such employer;
(B) A union on behalf of its members;
(C) A fully self-funded insurance plan meeting the definition of employee benefit plan as set forth in the Employee Retirement Income Security Act of 1974;
(D) An insurance company licensed in this state;
(E) A prepaid hospital or medical care plan;
(F) An insurance agent or broker licensed in this state when acting as an insurance agent or broker;
(G) A creditor on behalf of its debtors with respect to insurance covering a debt between the creditor and its debtors;
(H) A bank, credit union or other financial institution which is subject to supervision or examination by federal or state banking authorities when acting as a bank, credit union or other financial institution and not as an administrator;
(J) A credit card company which advances for and collects premiums or charges from its credit card holders who have authorized it to do so, provided such company does not adjust or settle claims;
(K) A person who adjusts or settles claims in the normal course of the person's practice or employment as an attorney at law or an adjuster licensed in this state and who does not collect charges or premiums in connection with insurance coverage or annuities.
26-53-102. Registration of third party administrators; rulemaking authority.
No person shall act as a third party administrator in this state without a certificate of registration issued by the commissioner. The commissioner in compliance with the Wyoming Administrative Procedure Act shall promulgate reasonable rules and regulations necessary to implement this chapter.
(a) This chapter is known and may be cited as the Wyoming Insurance Corporate Governance Annual Disclosure Act.
(b) The requirements of this act shall apply to all insurers and insurance groups domiciled in this state.
(c) Nothing in this act shall be construed to prescribe or impose corporate governance standards and internal procedures beyond that which is required under the corporate law of this state.
(d) Nothing in this act shall be construed to limit the commissioner's authority, or the rights or obligations of third parties, pursuant to the Wyoming Insurance Code.
(e) No insurer or insurance group shall be required to file the disclosure required by this act until 2020.
(a) As used in this act:
(i) "Corporate governance" means the system of rules, practices and procedures by which a corporation is managed by its directors and officers;
(ii) "Corporate governance annual disclosure" or "CGAD" means a confidential report filed by an insurer or insurance group in accordance with the requirements of this act;
(iii) "Insurance group" means those insurers and affiliates included within an insurance holding company system as defined under W.S. 26-44-101(a)(iv);
(iv) "Insurer" shall have the same meaning as set forth under W.S. 26-1-102(a)(xvi) and include domestic fraternal benefit societies and health maintenance organizations. This term shall not include agencies, authorities or instrumentalities of the United States, its possessions and territories, the Commonwealth of Puerto Rico, the District of Columbia, or a state or political subdivision of a state.
(a) An insurer, or the insurance group of which the insurer is a member, shall, no later than June 1 of each calendar year, submit to the commissioner a corporate governance annual disclosure that contains the information described in W.S. 26-54-105. Notwithstanding any request from the commissioner made pursuant to subsection (c) of this section, if the insurer is a member of an insurance group, the insurer shall submit the report required by this section to the commissioner of insurance of the lead state for the insurance group, in accordance with the laws of the lead state and under the guidance of the procedures outlined in the most recent financial analysis handbook adopted by the National Association of Insurance Commissioners.
(b) The CGAD shall include a signature of the insurer's or insurance group's chief executive officer or corporate secretary attesting to the best of that individual's belief and knowledge that the insurer has implemented the corporate governance practices disclosed pursuant to subsection (a) of this section and that a copy of the disclosure has been provided to the insurer's board of directors or the appropriate committee thereof.
(c) An insurer not required to submit a CGAD under this section shall do so upon the commissioner's request.
(d) For purposes of completing the CGAD, the insurer or insurance group may provide information regarding corporate governance at the ultimate controlling parent level, an intermediate holding company level or the individual legal entity level, depending upon how the insurer or insurance group has structured its system of corporate governance. The insurer or insurance group is encouraged to make the CGAD disclosures at the level at which the insurer's or insurance group's risk appetite is determined, or at which the earnings, capital, liquidity, operations, and reputation of the insurer are overseen collectively and at which the supervision of those factors are coordinated and exercised, or the level at which legal liability for failure of general corporate governance duties would be placed. If the insurer or insurance group determines the level of reporting based on these criteria, it shall indicate which of the three (3) criteria was used to determine the level of reporting and explain any subsequent changes in the level of reporting.
(e) The review of the CGAD and any additional requests for information shall be made through the lead state under the guidance of the procedures contained in the most recent financial analysis handbook referenced in subsection (a) of this section.
(f) Insurers providing information substantially similar to the information required by this act in other documents provided to the commissioner, including any statements filed pursuant to W.S. 26-44-104, or other state or federal filings provided to the department, shall not be required to duplicate that information in the CGAD, but shall be required to cross reference and identify where the document may be located by the commissioner.
The commissioner shall promulgate rules and regulations necessary to carry out the provisions of this act. The rules and regulations shall be consistent with this act and the commissioner shall be guided by the model regulations adopted by the National Association of Insurance Commissioners at its 2014 fall national meeting and subsequent provisions of those model regulations, provided the model regulations are consistent with this act and other relevant provisions of Wyoming law and are not inappropriate for Wyoming circumstances.
26-54-105. Contents of corporate governance annual disclosure.
(a) An insurer or insurance group shall have discretion over the manner in which a CGAD is submitted, provided the CGAD shall contain the material information necessary to permit the commissioner to gain an understanding of the insurer's or insurance group's corporate governance structure, policies and practices. The commissioner may request additional information deemed material and necessary to provide the commissioner with a clear understanding of corporate governance policies and the reporting, information systems or controls used to implement those policies.
(b) Notwithstanding subsection (a) of this section, the CGAD shall be prepared consistent with this subsection and corporate governance annual disclosure regulations adopted pursuant to W.S. 26-54-104. The CGAD shall describe:
(i) The insurer's or insurance group's corporate governance framework;
(ii) The policies and practices of the most senior governing entity and significant committees thereof;
(iii) Policies and practices for directing senior management; and
(iv) The processes by which the board and senior management ensure an appropriate amount of oversight to the critical risk areas impacting the insurer’s business activities.
(c) Documentation and supporting information relevant to the CGAD shall be maintained and made available for examination or upon request of the commissioner.
(a) Documents, materials or other information, including the CGAD, in the possession or control of the department that are obtained by, created by or disclosed to the commissioner or any other person under this act, are recognized by this state as being proprietary and to contain trade secrets. All the documents, materials or other information shall be confidential by law and privileged, shall not be considered public records pursuant to W.S. 16-4-201 through 16-4-205, shall not be subject to subpoena and shall not be subject to discovery or admissible as evidence in any private civil action. The commissioner is authorized to use the documents, materials or other information in the furtherance of any regulatory or legal action brought as a part of the commissioner's official duties. The commissioner shall not otherwise make the documents, materials or other information public without the prior written consent of the insurer. Nothing in this section shall be construed to require written consent of the insurer before the commissioner may share or receive documents, materials or other information pursuant to subsection (c) of this section and as necessary to assist in the performance of the commissioner's regular duties.
(b) Neither the commissioner nor any other person who receives documents, materials or other information subject to subsection (a) of this section, through examination or otherwise, while acting under the authority of the commissioner, or with whom such documents, materials or other information are shared pursuant to this act, shall testify in any private civil action concerning the documents, materials or other information.
(c) In order to assist in the performance of the commissioner's regulatory duties, the commissioner may:
(i) Upon request, share documents, materials or other information, including confidential and privileged documents, materials or other information, which may include proprietary or trade secret information, with other state, federal and international financial regulatory agencies, including members of any supervisory college as defined under W.S. 26-44-118, with the National Association of Insurance Commissioners and with third party consultants pursuant to W.S. 26-54-107, provided that the recipient agrees in writing to maintain the confidentiality and privileged status of the documents, materials or other information and has verified in writing the legal authority to maintain confidentiality;
(ii) Receive documents, materials or other information, including confidential and privileged documents, materials or other information, which may include proprietary or trade secret information, from regulatory officials of other state, federal and international financial regulatory agencies, including members of any supervisory college as defined under W.S. 26-44-118 and from the National Association of Insurance Commissioners. The commissioner shall maintain as confidential and privileged any documents, materials or other information received under this paragraph with notice or the understanding that it is confidential and privileged under the law of the jurisdiction that is the source of the document, materials or other information.
(d) The sharing of documents, materials or other information by the commissioner pursuant to this act shall not constitute a delegation of regulatory authority or rulemaking, and the commissioner is solely responsible for the administration, execution and enforcement of the provisions of this act.
(e) No waiver of any applicable privilege or claim of confidentiality in the documents, materials or other information shall occur as a result of disclosure of such information to the commissioner under this section or as a result of any sharing authorized by this act.
(f) Information that is disclosed in the CGAD which is also contained in any public filing or is otherwise publicly disclosed by the insurer shall not be considered privileged or confidential.
(a) The commissioner may retain, at the insurer's expense, third party consultants, including attorneys, actuaries, accountants and other experts not otherwise a part of the commissioner's staff, as may be reasonably necessary to assist the commissioner in reviewing the CGAD and related information submitted by an insurer or to determine an insurer’s compliance with this act.
(b) Any consultant retained under subsection (a) of this section shall act only as an independent contractor within the scope of duties established by the commissioner.
(c) The National Association of Insurance Commissioners and any person retained pursuant to subsection (a) of this section shall be subject to the same confidentiality standards and requirements as the commissioner.
(d) A third party consultant retained pursuant to subsection (a) of this section shall verify to the commissioner, with notice to the insurer, that he is free of a conflict of interest and that, if applicable, the consultant's firm has internal procedures in place to monitor compliance with a conflict and to comply with the confidentiality standards and requirements of this act.
(e) The commissioner shall enter into a written agreement with the National Association of Insurance Commissioners and any person retained pursuant to subsection (a) of this section concerning the sharing and use of information provided under this act. Consistent with W.S. 26-2-113, the agreement shall contain the following provisions and expressly require the written consent of the insurer prior to making public any information provided under this act:
(i) Specific procedures and protocols for maintaining the confidentiality and security of CGAD related information shared with the National Association of Insurance Commissioners or any person retained pursuant to subsection (a) of this section;
(ii) Procedures and protocols for the National Association of Insurance Commissioners, or other persons retained pursuant to subsection (a) of this section, to disclose CGAD related information to other state regulators from states in which an insurance group has domiciled insurers. The agreement shall provide that the recipient agrees in writing to maintain the confidentiality and privileged status of the CGAD related documents, materials or other information and has verified in writing the legal authority to maintain confidentiality;
(iii) A provision specifying that ownership of CGAD related information shared with the National Association of Insurance Commissioners or a person retained pursuant to subsection (a) of this section remains with the department and use of the information by the National Association of Insurance Commissioners or a person retained pursuant to subsection (a) of this section is subject to the direction of the commissioner;
(iv) A provision that prohibits the National Association of Insurance Commissioners or any person retained pursuant to subsection (a) of this section from storing the information shared pursuant to this act in a permanent database after the underlying analysis is completed;
(v) A provision requiring the National Association of Insurance Commissioners or any person retained pursuant to subsection (a) of this section to provide prompt notice to the commissioner and to the insurer or insurance group upon the receipt of any subpoena, request for disclosure, or request for production of the insurer's or insurance group’s CGAD related information; and
(vi) A requirement that the National Association of Insurance Commissioners or any person retained pursuant to subsection (a) of this section shall consent to intervention by an insurer in any judicial or administrative action in which the National Association of Insurance Commissioners or the person retained pursuant to subsection (a) of this section may be required to disclose confidential information about the insurer shared with the National Association of Insurance Commissioners or a person retained pursuant to subsection (a) of this section.
Any insurer failing, without just cause, to timely file the CGAD required by this act shall be required, after notice and hearing, to pay a penalty of one hundred dollars ($100.00) for each day that the CGAD is not filed, to be recovered by the commissioner. The maximum penalty due under this section shall be five thousand dollars ($5,000.00). The commissioner may reduce the penalty if the insurer demonstrates to the commissioner that the imposition of the penalty would constitute a financial hardship to the insurer.
(a) As used in this act:
(i) "Adverse determination" means a decision by a health insurer or contracted utilization review entity to deny, reduce or terminate benefit coverage for health care services furnished or proposed to be furnished because the services are not medically necessary or are experimental or investigational. A decision to deny, reduce or terminate health care services that are not covered for reasons other than their medical necessity or experimental or investigational nature is not an "adverse determination" for purposes of this act;
(ii) "Authorization" means an approved prior authorization request;
(iii) "Chronic or long-term care condition" means a condition that lasts not less than three (3) months and requires ongoing medical attention, limits activities of daily living or both;
(iv) "Enrollee" means a person eligible to receive health care benefits by a health insurer pursuant to a health plan or other health insurance coverage. The term "enrollee" includes an enrollee's legally authorized representative;
(v) "Health care service" means health care procedures, treatments or services provided by a licensed health care facility or provided by a licensed physician or licensed health care provider. The term "health care service" also includes the provision of pharmaceutical products or services and durable medical equipment;
(vi) "Health insurer or contracted utilization review entity" means a person or entity that performs prior authorization for one (1) or more of the following entities:
(A) An employer with employees in Wyoming who are covered under a health benefit plan, disability insurance as defined by W.S. 26-5-103 or a health insurance policy;
(B) An insurer that writes health insurance policies;
(C) A preferred provider organization or health maintenance organization.
(vii) "Medically necessary health care services" means as defined by W.S. 26-40-102(a)(iii);
(viii) "Medications for opioid use disorder" means the use of medications to provide a comprehensive approach to the treatment of opioid use disorder. United States food and drug administration approved medications used to treat opioid addiction include methadone, buprenorphine, alone or in combination with naloxone, and extended-release injectable naltrexone;
(ix) "Prior authorization" means the process by which health insurers or contracted utilization review entities determine the medical necessity or medical appropriateness of otherwise covered health care services prior to rendering such health care services. "Prior authorization" also includes any health insurer or contracted utilization review entity's requirement that an enrollee or health care provider notify the health insurer or contracted utilization review entity prior to providing a health care service;
(x) "Urgent health care service" means a health care service for which the application of the time periods for making a nonexpedited prior authorization decision could, in the opinion of a physician with knowledge of the enrollee's medical condition:
(A) Seriously jeopardize the life or health of the enrollee or the ability of the enrollee to regain maximum function; or
(B) Could subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the review. For purposes of this act, urgent health care service shall include mental and behavioral health care services.
(xi) "Step therapy protocol" means an evidence-based protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are deemed medically appropriate for a particular patient and are covered by a health insurer or health benefit plan;
(xii) "Health care provider" means a person licensed, registered or certified under federal or state laws or regulations to provide health care services;
(xiii) "This act" means W.S. 26-55-101 through 26-55-113.
26-55-103. Disclosure and review of prior authorization requirements.
(a) Each health insurer or contracted utilization review entity shall make any current prior authorization requirements and restrictions easily accessible on its website to enrollees, health care providers and the general public. Each health insurer or contracted utilization review entity shall directly furnish those requirements and restrictions within twenty-four (24) hours after being requested by a health care provider. Requirements and restrictions provided or posted under this subsection shall be described in detail but also in easily understandable language. Content published by a third party and licensed for use by a health insurer or contracted utilization review entity may be made available through the health insurer or contracted utilization review entity's secure password protected website, provided that the access requirements of the website do not unreasonably restrict access to any current prior authorization requirements and restrictions.
(b) Each health insurer or contracted utilization review entity shall not implement a new or amended prior authorization requirement or restriction unless its website has been updated to reflect the new or amended prior authorization requirement or restriction.
(c) Each health insurer or contracted utilization review entity shall provide affected contracted health care providers and enrollees written notice of any new or amended prior authorization requirement or restriction implemented under the health insurer's medical policy or the health insurance contract not less than sixty (60) days before the new or amended prior authorization requirement or restriction is implemented.
(d) The department of insurance shall promulgate rules requiring health insurers or contracted utilization review entities to make statistics available to the public and the department regarding prior authorizations and adverse determinations. At a minimum, the statistics shall include categories for:
(i) The health care provider specialty;
(ii) The medication or diagnostic test or procedure;
(iii) The indication offered;
(iv) The reason for the adverse determination;
(v) Whether the adverse determination was appealed;
(vi) Whether the adverse determination was upheld or reversed on appeal;
(vii) The time between submission of the prior authorization request and the authorization or initial adverse determination.
26-55-104. Persons qualified to make adverse determinations.
(a) Each health insurer or contracted utilization review entity shall ensure that all adverse determinations are made by a physician or other appropriate licensed health care provider who has:
(i) Sufficient medical knowledge in an applicable practice area or specialty;
(ii) Knowledge of the coverage criteria;
(iii) Unless otherwise required under Wyoming law, a current and unrestricted license to practice within the scope of their profession in a state, territory, commonwealth of the United States or the District of Columbia;
(iv) Knowledge of the applicable person's medical history and diagnosis.
26-55-105. Consultation after issuing an adverse determination.
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 with the person who has decision making authority and will be responsible for determining authorization of the health care service under review. The health insurer or contract utilization review entity shall attempt to schedule the discussion within five (5) business days after the health care provider's request.
26-55-106. Requirements applicable to persons reviewing appeals.
(a) Each health insurer or contracted utilization review entity shall ensure that all appeals of adverse determinations are reviewed by a physician or other appropriate licensed health care provider who has:
(i) Sufficient medical knowledge in an applicable practice area or specialty;
(ii) Knowledge of the coverage criteria;
(iii) A current and unrestricted license to practice within the scope of their medical profession in a state, territory, commonwealth of the United States or the District of Columbia;
(iv) Not been employed by the health insurer or contracted utilization review entity or been under contract with the health insurer or contracted utilization review entity other than to participate in one (1) or more of the health insurer or contracted utilization review entity's health care provider networks or to perform reviews of appeals, or otherwise have any financial interest in the outcome of the appeal;
(v) Not been directly involved in the initial adverse determination; and
(vi) Considered all known clinical aspects of the health care service under review, including but not limited to, a review of all pertinent medical records provided to the health insurer or contracted utilization review entity by the enrollee's health care provider, any relevant records provided to the health insurer or contracted utilization review entity by a health care facility, any pertinent material provided by the enrollee and any medical literature provided to the health insurer or contracted utilization review entity by the health care provider.
(b) The enrollee's health care provider may request upon the initiation of an appeal that the appeal from an adverse determination be made by a physician or a specialist in the area of medicine under appeal.
26-55-107. Health insurer or contracted utilization review
entities' obligations regarding prior authorization for nonurgent health care services If a health insurer or contracted utilization review entity requires prior authorization of a health care service, the health insurer or contracted utilization review entity shall make an authorization or adverse determination and notify the enrollee and the enrollee's health care provider of the authorization or adverse determination within five (5) calendar days of obtaining all necessary information to complete the review.
26-55-108. Health insurer or contracted utilization review
entities' obligations with respect to prior authorizations for urgent health care services. Each health insurer or contracted utilization review entity shall make an authorization or adverse determination concerning urgent health care services and notify the enrollee and the enrollee's health care provider of that authorization or adverse determination not later than seventy-two (72) hours after receiving all necessary information to complete the review. The prior authorization request shall be considered authorized if the health insurer or contracted utilization review entity fails to notify the enrollee and the health care provider of a decision within seventy-two (72) hours of receiving all necessary information to complete the review. A health insurer or contracted utilization review entity shall provide an online portal for health care providers to have the option of submitting urgent prior authorization requests for urgent health care services.
26-55-110. Length of authorization generally; revocation
of prior authorizations prohibited; length of authorization for chronic or long-term care conditions.
(a) Each authorization shall have the following timelines:
(i) Outpatient service prior authorizations shall be valid for a period of not less than one (1) year;
(ii) Prescription drug authorization periods shall be effective for a period of not less than one (1) year including changes in dosage for a prescription drug prescribed by a health care provider, provided that the authorization period and dosage change are consistent with dosing and duration according to evidence-based guidelines for safety and efficacy;
(iii) Prior authorizations for inpatient services shall be valid for a length of time based on the patient's clinical condition. This period will be not less than one (1) day.
(b) Each health insurer or contracted utilization review entity shall not revoke, limit, condition or restrict a previously approved authorization for health care services if the health care services are provided within forty-five (45) business days from the date the health care provider received the authorization approval for the specific service that was authorized.
(c) If a health insurer or contracted utilization review entity requires a prior authorization request for a health care service for the treatment of a chronic or long-term care condition, the authorization shall remain valid for one (1) year. This section shall not apply to the prescription of benzodiazepines or schedule II narcotic drugs.
(a) On receipt of all necessary information documenting an authorization from the enrollee, previous health insurer or the enrollee's health care provider, a health insurer or contracted utilization review entity shall honor an authorization granted to an enrollee from a previous health insurer or contracted utilization review entity for not less than ninety (90) days after an enrollee's coverage under a new health plan commences, if the health care service is a covered benefit under the new health insurance plan.
(b) During the time period described in subsection (a) of this section, a health insurer or contracted utilization review entity may perform its own review to grant a new authorization.
(c) If there is a change in coverage of, or a change in approval criteria for, a previously authorized health care service under the enrollee's current health care plan, the change in coverage or approval criteria shall not affect an enrollee who received authorization less than one (1) year before the effective date of the change. A health insurer or contracted utilization review entity may require a new prior authorization request one (1) year after the enrollee's previous prior authorization was requested.
(d) No enrollee shall be required to repeat a step therapy protocol if that enrollee, while under their current or a previous health benefit plan, used the prescription drug required by the step therapy protocol, or another prescription drug in the same pharmacologic class with a similar efficacy and side effect profile or with the same mechanism of action, and discontinued use due to lack of efficacy, effectiveness, an adverse event or contraindication. The enrollee's prescribing provider shall submit justification and clinical information, if requested, that demonstrates a clinically valid reason for why the covered prescribed drug is needed and documentation of completion of previous step therapy protocols for the prescribed drug.
26-55-112. Provider exemptions from prior authorization requirements.
(a) A health care provider, as identified by a unique national provider identifier, shall be granted a twelve (12) month or one (1) year exemption from completing a prior authorization request for a health care service, excluding the practice of pharmacy and prescription drugs, if:
(i) In the most recent twelve (12) month period, the health insurer or contracted utilization review entity has authorized not less than ninety percent (90%) of the prior authorization requests, rounded down to the nearest whole number, submitted by the health care provider for that health care service; and
(ii) The health care provider has made a prior authorization request for that health care service not less than five (5) times in the most recent twelve (12) month period.
(b) A health insurer or contracted utilization review entity may evaluate whether a health care provider continues to qualify for exemptions as described in subsection (a) of this section. Nothing in this section shall require a health insurer or contracted utilization review entity to evaluate an existing exemption under subsection (a) of this section or prevent a health insurer or contracted utilization review entity from establishing a longer exemption period.
(c) A health care provider is not required to request an exemption in order to receive an exemption under subsection (a) of this section.
(d) A health care provider who does not receive an exemption under subsection (a) of this section may request from the health insurer or contracted utilization review entity up to one (1) time per calendar year per service, evidence to support the health insurer or contracted utilization review entity's decision. A health care provider may appeal a health insurer or contracted utilization review entity's decision to deny an exemption.
(e) A health insurer or contracted utilization review entity shall only revoke an exemption at the end of a twelve (12) month period if the health insurer or contracted utilization review entity:
(i) Makes a determination that the health care provider would not have met the ninety percent (90%), rounded down to the nearest whole number, authorization criteria based on a retrospective review of the claims for the particular service for which the exemption applies;
(ii) Provides the health care provider with the information it relied upon in making its determination to revoke the exemption; and
(iii) Provides the health care provider a plain language explanation of how to appeal the decision.
(f) An exemption under subsection (a) of this section shall remain in effect until the thirtieth day after the date the health insurer or contracted utilization review entity notifies the health care provider of its determination to revoke the exemption or, if the health care provider appeals the determination, the fifth day after the revocation is upheld on appeal.
(g) A determination to revoke or deny an exemption under subsection (a) of this section shall be made by a licensed health care provider that is of the same or similar specialty as the health care provider being considered for an exemption and has experience in providing the service for which the potential exemption applies.
(h) A health insurer or contracted utilization review entity shall provide a health care provider that receives an exemption under subsection (a) of this section a notice that includes:
(i) A statement that the health care provider qualifies for an exemption from prior authorization requirements;
(ii) A list of services for which the exemption applies; and
(iii) A statement of the twelve (12) month duration of the exemption.
(j) No health insurer or contracted utilization review entity shall deny or reduce payment for a health care service exempted from a prior authorization requirement under this section, including a health care service performed or supervised by another health care provider when the health care provider who ordered such service received a prior authorization exemption, unless the rendering health care provider:
(i) Knowingly and materially misrepresented the health care service in request for payment submitted to the health insurer or contracted utilization review entity with the specific intent to deceive and obtain an unlawful payment from the health insurer or contracted utilization review entity; or
(ii) Failed to substantially perform the health care service.
26-55-113. Prior authorization for rehabilitative or habilitative services.
(a) A health insurer or contracted utilization review entity shall not require prior authorization for rehabilitative or habilitative services including, but not limited to, physical therapy services or occupational therapy services for the first twelve (12) visits for each new episode of care. For purposes of this subsection, "new episode of care" means treatment for a new condition or treatment for a recurring condition that an enrollee has not been treated within the previous ninety (90) days.
(b) This section does not limit the right of a health insurer or contracted utilization review entity to deny a claim when an appropriate prospective or retrospective review concludes that the health care services were not medically necessary.
(a) As used in this chapter:
(i) "Applicant" means a health care provider who submits an application to a health carrier to become credentialed as a participating health care provider in one (1) or more of the health carrier's provider networks;
(ii) "Application" means an applicant's most recent application to become credentialed by a health carrier as a participating health care provider in one (1) or more of the health carrier's provider networks;
(iii) "Completed credentialing application" means a credentialing application that is free of defects and contains all of the information that, when later supplemented by verification and documentation gathered by the health carrier during the primary source verification process, is necessary for the health carrier to make a credentialing decision;
(iv) "Credentialing" means the process by which a health carrier or its designee collects information concerning an applicant, assesses whether the applicant satisfies the requirements to become a participating health care provider in one (1) or more of the health carrier's provider networks, verifies all information submitted by the applicant and approves or denies the applicant's application;
(v) "Health carrier" means as defined by W.S. 26-13-303(a)(iii) and shall not mean pharmacy benefit managers as defined by W.S. 26-52-102(a)(vii).