Section 18.11. Independent review.

 

(1)   Independent review procedures. Each insurer offering a health benefit plan shall establish procedures to ensure compliance with this section and s. 632.835 , Stats.

(2)   Notification of right to independent review. In addition to the requirements of s. 632.835 (2) (b) or (2) (bg) , Stats., and s. Ins 18.03 , each time an insurer offering a health benefit plan makes a coverage denial determination the insurer shall provide all of the following in the notice to the insureds:

(a) A notice to an insured of the right to request an independent review. The notice shall comply with s. 632.835 (2) (b) or (2) (bg) , Stats., and when required, to be accompanied by the informational brochure developed by the office or in a form substantially similar, describe the independent review process. The notice shall be sent when the insurer offering a health benefit plan makes a coverage denial determination. In addition, the notice shall contain all of the following information:

2. For coverage denial determinations occurring after June 15, 2002, the notice to an insured shall, in accordance with s. 632.835 (2) (c) , Stats., state that the insured, or the insured's authorized representative, must request independent review within 4 months from the date of the coverage denial determination by the insurer or from the date of receipt of notice of the grievance panel decision, whichever is later.

3. The notice shall state that the insured, or the insured's authorized representative, shall select the independent review organization from the list of certified independent review organizations, accompanying the notice, as compiled by the commissioner and available from the insurer.

4. The notice shall state that the insured's, or the insured's authorized representative's, request for an independent review must be made in writing and contain the name of the selected independent review organization. The notice shall also state that the insured's, or the insured's authorized representative, written request be submitted to the insurer and must contain the address and name of the person or position to whom the request is to be sent.

5. The notice shall include a statement that references s. 632.835 (3) (f) , Stats., informing the insured that once the independent review organization makes a determination, the determination may be binding upon the insurer and insured. For preexisting condition exclusion and rescission denial determinations, the notice shall indicate that the independent review organization determination is not binding on the insured.

6. The notice shall include a statement that references s. 632.835 (2) (d) , Stats., informing the insured, or the insured's authorized representative, that they need not exhaust the internal grievance procedure if either of the following conditions are met:

a. Both the insurer offering a health benefit plan and the insured, or the insured's authorized representative, agree that the appeal should proceed directly to independent review.

b. The independent review organization determines that an expedited review is appropriate upon receiving a request from an insured or the insured's authorized representative that is simultaneously sent to the insurer offering a health benefit plan.

7. The notice shall include a brief summary statement regarding Health Insurance Risk Sharing Plan eligibility as required in s. 632.785 , Stats., when the coverage denial determination involved a policy rescission.

(b)

1. For preexisting condition exclusion denial and rescission determinations that occur on or after January 1, 2010, but prior to the date stated in the notice published by the commissioner in the Wisconsin Administrative Register under s. 632.835 (8) (b) , Stats., the notice to an insured shall state that the insured, or the insured's authorized representative, must request the independent review within 4 months from the date stated in the notice published by the commissioner in the Wisconsin Administrative Register under s. 632.835 (8) (b) , Stats.

2. For preexisting condition exclusion denial and rescission determinations occurring subsequent to the date stated in the notice published by the commissioner in the Wisconsin Administrative Register under s. 632.835 (8) (b) , Stats., the notice to an insured shall comply with sub. (2) (a) , state that the insured, or the insured's authorized representative, must request the independent review within 4 months from the date of the preexisting condition exclusion denial or rescission determination by the insurer or from the date of receipt of notice of the grievance panel decision, whichever is later.

(3)   Independent review timeframes. In addition to the requirements set forth in s. 632.835 (3) , Stats., the following procedures shall be followed:

(a) The insurer offering a health benefit plan, upon receipt of a request for independent review, shall provide written notice of the request to the commissioner and to the independent review organization selected by the insured or the insured's authorized representative within 2 business days of receipt.

(b) The insurer offering a health benefit plan shall provide the information required in s. 632.835 (3) (b) , Stats., to the independent review organization without requiring a written release from the insured in accordance with s. 610.70 (5) (f) , Stats.

(bm) The insurer offering a health benefit plan shall provide, upon written request from the insurer or the insured's authorized representative, a complete copy of the insured's policy. The insurer offering a health benefit plan shall respond to the written request within 3 business days of the request by mailing or electronically mailing the copy to the insured or the insured's authorized representative in the format requested.

(c) Information submitted to the independent review organization at the request of the independent review organization by either the insurer or the insured, or the insured's authorized representative, shall also be promptly provided to the other party to the review.

(d) Paragraphs (a) to (c) do not apply to situations where the independent review organization determines that the normal duration of the independent review process would jeopardize the life or health of the insured or the insured's ability to regain maximum function. For these situations, the independent review organization shall develop a separate expedited review procedure for expedited situations which complies with s. 632.835 (3) (g) , Stats. An expedited review shall be conducted in accordance with s. 632.835 (3) (g) 1. to 4. , Stats., and shall be resolved as expeditiously as the insured's health condition requires.

(4)   Disputes.

(a) A dispute between an insured and an insurer regarding eligibility for independent review shall be considered a coverage denial determination and the insured may seek independent review of the determination in accordance with this section.

(b) Disputes that are related to administrative matters, including enrollment eligibility, not related to treatment or services are not eligible for independent review determinations.

CR 00-169 : cr. Register November 2001 No. 551 , eff. 12-1-01; CR 04-079 : am. (2) (a) 3. Register December 2004 No. 588 , eff. 1-1-05; CR 10-023 : am. (2) (intro.), (a) (intro.), 2., 4., 5., r. (2) (a) 1., cr. (2) (a) 7., (b), (3) (bm), (4) Register September 2010 No. 657 , eff. 10-1-10.

Note

The commissioner maintains a current listing, revised at least quarterly, of certified independent review organizations and posts the current list on the office website: http://oci.wi.gov . Microsoft Windows NT 6.1.7601 Service Pack 1