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Wyoming Provider Request for Preauthorization Review

Wyoming surgeons use this one-page request when they want the Workers' Compensation Division to review a planned surgery or procedure before it happens. Preauthorization is voluntary in Wyoming, and urgent or emergent procedures proceed without it. A Division preauthorization nurse completes the bottom block and returns the form with a preauthorization number, or the file may go to peer review, an IME or a second opinion.

Who completes it

The requesting surgeon's office completes everything above the nurse block: claimant and claim details, surgeon NPI and tax ID, contact person, diagnosis, ICD-10-CM and CPT codes, procedure side and spinal levels, date, work-relatedness and expected recovery. Only the Division's preauthorization nurse completes the authorization section.

Submitting and payment

How to submit it
Send the form by fax, email or mail to the Division's preauthorization unit before treatment, with the signed office note, diagnostic reports from the last 12 months and any required check sheet. Expect a decision within 60 calendar days of receipt under W.S. 27-14-601(k).
Who pays
No fee is attached to the request itself; the procedure is billed to Wyoming Workers' Compensation afterward and paid under the Division's fee schedule.

Good to know

  • A completed check sheet is required when requesting a spinal cord or dorsal root ganglion stimulator, cervical or lumbar spinal fusion, SI fusion or artificial disc replacement.
  • Attach a current office visit note with physical exam that discusses the proposed procedure and is signed by the requesting surgeon, defined as the person who will perform it.
  • The request must also include a copy of the requesting surgeon's board certification as a surgeon, along with the surgeon's contact person, phone and fax.
  • A Division response may be neither an approval nor a denial; the nurse may contact the office when the file is sent for peer review, IME or second opinion.

Get the official form

Download the current version from the source each time; forms change without notice.

Provider Request for Preauthorization Review

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Is preauthorization required for surgery in Wyoming workers' comp?

No. The Division reviews surgical procedures for preauthorization only on a voluntary basis, and its claimant guide says each provider decides whether it wants preauthorization for its business. For emergent or urgent procedures, life-threatening conditions or rapidly progressing deterioration, the provider should proceed with medically necessary care without preauthorization.

How long does Wyoming take to decide a preauthorization request?

Under W.S. 27-14-601(k), the Division's timeframe is 60 calendar days from receipt of the request form. Approved requests come back by fax or email with an assigned preauthorization number, and the nurse may contact the office if the file is sent for peer review, an independent medical exam or a second opinion.

Which version of the Wyoming preauthorization form should I use?

The Division posts the Provider Request for Preauthorization Review in printable and non-printable versions on its preauthorization page, currently revised 9/25. Either way, complete it entirely: the Division expects injured worker details, surgeon information, diagnosis, ICD-10 and CPT codes and the written procedure on every request.