Chapter 1

Direct Payment or Reimbursement of Medical Expenses

 

Section 1. Authority. These rules are promulgated by the Adjutant General under the authority given by Wyoming Statute 19-9-403(a).

 

Section 2. Definitions.

 

(a)                      "Medical expense" means expenses related to customary treatment by a licensed doctor of medicine, chiropractic or osteopathy, dentist, optometrist, podiatrist, psychologist, physician's assistant, and advance practitioner of nursing acting within the scope of his or her license. Medical expense also includes expenses for prescription medications, surgical or hospital service, medical and surgical supplies, apparatus, essential and adequate artificial replacement, and prosthetics.

 

(b)                     "Reasonable medical expense" means those charges for medical expenses that are necessary and determined reasonable by reference to charges and quantity of services normally allowed by the State of Wyoming's employee group health insurance, Medicare, Medicaid customary charges in the area for similar services, and any other relevant sources related to the particular expense at issue. Direct payment or reimbursement may be limited to the lowest levels generally accepted by health care providers for providing similar services in the State of Wyoming.

 

(c)                      "State active duty" means that time during which an officer or enlisted man is serving on state active duty orders or traveling to or from any location in relation to performing state active duty.

 

Section 3. Initial Reporting Requirement.

 

(a)                      Prompt reporting is essential to determine whether medical expenses are reasonable and are a direct consequence of state active duty.

 

(b)                     The occurrence of any medical condition giving rise to a claim under W.S. 19-9-403(a) shall be reported within the time period below in writing to the Wyoming Military Department Human Resources Office, on a reporting form approved by that office, and contain all information required by the form. The officer or enlisted man (also collectively referred to as "member") shall file a completed reporting form before the completion of the period of state active duty giving rise to the claim or within forty-eight (48) hours after the time that a reasonable person would have recognized that he or she had suffered a medical condition potentially covered under W.S 19-9-403(a), whichever time period is shorter. Failure to comply with this requirement shall constitute a basis for denying the claim.

 

(c)                      At a minimum, the reporting form approved by the Military Department Human Resources Office shall include the following, with all information certified to be true by the member:

 

(i)                 Name, unit, home address, and dates of state active duty;

 

(ii)               A complete and detailed description of the alleged medical condition and any factors believed to have caused the condition;

 

(iii)            Any health care providers seen by the member for the condition;

 

(iv)             Any witnesses that may have knowledge related to the medical condition;

 

(v)              Any previous treatment by the member for the same or similar condition in the past;

 

(vi)             A release and authorization allowing the Wyoming Military Department Human Resources Office to obtain treatment or medical reports related to the member;

 

(vii)           A list and description of any health insurance coverage that the member may have; and

 

(viii)        Such other information as the Wyoming Military Department Human Resources Office may require to assist it in determining the claim.

 

Section 4. Utilization of Other Payment Sources. Any claim for medical expenses may be denied to the extent that the expense is or was reasonably eligible for payment, coverage or reimbursement from any other source including, but not limited to, other governmental benefits, health insurance, workers' compensation, any other form of insurance or medical payment coverage, or any other entity that may be legally liable for payment of the medical expense at issue. The payment of medical expenses under W.S. 19-9-403(a) may be denied if coverage from another source was reasonably available, regardless of whether the member has taken the appropriate measures to apply for or require payment from any other party.

 

Section 5. Claims for Reimbursement.

 

(a)                In addition to the reporting requirement in Section 3, all claims for direct payment or reimbursement of reasonable medical expenses shall be submitted to the Wyoming Military Department Human Resources Office within forty-five (45) days of the date that payment is due or made by the officer or enlisted man seeking reimbursement and shall be sworn to under oath by the member and contain information necessary to determine the amount of payment or reimbursement.

 

(b)               The Human Resources Office shall design a form to facilitate the submission of claims.

 

(c)                All claims shall be accompanied by a treatment report from the medical provider, a copy of any bill for services, medications or supplies, receipt indicating amount paid by the member, documentation of submittal for or payment made by any insurance carrier or third party, and other documentation substantiating the amount of direct payment to a provider or reimbursement for which the member may be eligible

 

Section 6. Investigation.

 

(a)                The Wyoming Military Department Human Resources Office shall be responsible for investigating all claims for medical expense payment or reimbursement under W.S. 19-9-403(a) and preparing a written decision that shall be sent to the member.

 

(b)         All claims for payment or reimbursement of reasonable medical expenses shall be investigated to the extent necessary to determine whether the claimed medical expense is reasonable, whether the expense is a direct consequence of state active duty, and the extent to which any insurance carrier, other governmental entity, or other party may have potential legal liability for payment of the medical expense at issue.

 

(c)                In conducting its investigation, the Human Resources Office may obtain statements from witnesses, review documents, and consult with experts upon matters relevant to a determination of the claim. The member may be required to produce any relevant information. In cases in which the complexity of the matter requires it, the Human Resources Office may request that the Adjutant General appoint an Investigating Officer to conduct an investigation.

 

Section 7. Determination of Claims.

 

(a)                While serving in state active duty, the adjutant general may pay or reimburse reasonable medical expenses incurred by an officer or enlisted man as a direct consequence of state active duty. Medical expenses paid or reasonably eligible for payment by any third party on behalf of the officer or enlisted man shall not be eligible for payment or reimbursement.

 

(b)          Medical expenses are the direct consequence of state active duty if the medical expense is for the treatment of a medical condition that arises out of and in the course of the member's service in state active duty, except that it shall not include medical expenses resulting from medical conditions due to gross negligence, intoxication, or culpable misconduct of the member receiving medical treatment.

 

(c)         Only reasonable medical expenses paid or payable by the officer or enlisted man as a direct consequence of state active duty will be allowed for direct payment to a provider or reimbursement.

 

(d)         Following its investigation, the Human Resources Office shall promptly make its written decision. If the Human Resources Office denies any claim, it shall serve by mail or personal delivery a copy of its written findings and decision to the member and a copy to the Adjutant General, advising the member that he/she has fifteen (15) calendar days from the date the decision was mailed or personally delivered to the member to request a hearing, in writing, before the Adjutant General. The request shall state the reason and basis for the request and disagreement with the Human Resources Office's decision. If a member fails to request a hearing within fifteen (15) calendar days from service of the Human Resources Office's decision, the Human Resources Office's decision shall become final.

 

(e)           If the member timely requests a hearing, the Adjutant General shall forward the matter to the Office of Administrative Hearings (OAH) to conduct a hearing and provide a recommended decision. Following receipt of the OAH's recommended decision, the Adjutant General shall make the final decision.

 

(f)         The Adjutant General's final decision shall be sent to the member by mail or personal delivery.

 

Section 8. Reconsideration and Recoupment from Claimant. The Adjutant General may seek recoupment by any lawful means for any payments made by the State of Wyoming pursuant to W.S. 19-9-403(a) based upon a mistake of law or fact or misrepresentation. Under no circumstances will a decision to make direct payment to a provider or allow reimbursement for any claims under W.S. 19-9-403(a) bind the Adjutant General to pay or reimburse further or additional claims.