Section 26-55-102 - Definitions(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.Added by Laws 2024, ch. 19,§ 1, eff. 7/1/2024.