Wisconsin Administrative Code › Office of the Commissioner of Insurance › Chapter Ins 18 - Health benefit plan grievances and independent review organizations certification and review procedures › Subchapter III - Independent Review Procedures › Section Ins 18.11 - Independent review

Current through June 24, 2024
(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.
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
.
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.