Chapter Ins 18

Ins 18.01 Ins 18.01 Definitions. In this chapter:

Ins 18.01(1) (1) “Commissioner” means the “commissioner of insurance” of this state or the commissioner’s designee.

Ins 18.01(2) (2) “Complaint” means any expression of dissatisfaction expressed to the insurer by the insured, or an insured’s authorized representative, about an insurer or its providers with whom the insurer has a direct or indirect contract.

Ins 18.01(2m) (2m) “Coverage denial determination” has the meaning as defined in s. 632.835 (1) (ag), Stats., and includes, for individual insurance products, a policy reformation or change in premium charged based upon underwriting or claims information greater than 25% from the premium in effect during the period of contestability except to the extent the modification is due to the applicant’s age or a rate increase applied by the insurer to all similar individual policy forms applied uniformly.

Ins 18.01(3) (3) “Expedited grievance” means a grievance where any of the following applies:

Ins 18.01(3)(a) (a) The duration of the standard resolution process will result in serious jeopardy to the life or health of the insured or the ability of the insured to regain maximum function.

Ins 18.01(3)(b) (b) In the opinion of a physician with knowledge of the insured’s medical condition, the insured is subject to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance.

Ins 18.01(3)(c) (c) A physician with knowledge of the insured’s medical condition determines that the grievance shall be treated as an expedited grievance.

Ins 18.01(4) (4) “Grievance” means any dissatisfaction with an insurer offering a health benefit plan or administration of a health benefit plan by the insurer that is expressed in writing to the insurer by, or on behalf of, an insured including any of the following:

Ins 18.01(4)(a) (a) Provision of services.

Ins 18.01(4)(b) (b) Determination to reform or rescind a policy.

Ins 18.01(4)(c) (c) Determination of a diagnosis or level of service required for evidence-based treatment of autism spectrum disorders.

Ins 18.01(4)(d) (d) Claims practices.

Ins 18.01(5) (5) “Independent review organizations” means an organization certified under s. 632.835 (4), Stats.

Ins 18.01(6) (6) “Independent review” means a review conducted by a certified independent review organization.

Ins 18.01(7) (7) “Insured” has the meaning provided in s. 600.03 (23), Stats.

Ins 18.01(8) (8) “OCI complaint” means any complaint received by the office of the commissioner of insurance by, or on behalf of, an insured of an insurer offering coverage under a health benefit plan.

Ins 18.01(9) (9) “Office” means the “office of the commissioner of insurance.”

Ins 18.01(10) (10) “Rescission” or “reformation” of a policy means a determination by an insurer offering health benefit plan, subject to s. 628.34 (3), Stats., to withdraw the coverage back to the initial date of coverage, modify the terms of the policy or adjust the premium rate by more than 25% from the premium in effect during the period of contestability. A modification in premium based upon the applicant’s or insured’s age or a rate increase uniformly applied by the insurer to all similar individual policy forms is not a rescission or reformation of a policy.

Ins 18.01 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 10-023: cr. (2m), (10), am. (4) Register September 2010 No. 657, eff. 10-1-10.

subch. II of ch. Ins 18 Subchapter II — Grievance Procedures

Ins 18.02 Ins 18.02 Definitions. In addition to the definitions in s. 632.83, Stats., in this subchapter:

Ins 18.02(1) (1) “Health benefit plan” has the meaning provided in s. 632.83, Stats., and includes Medicare supplement and Medicare replacement plans as defined in s. 600.03 (28p) and (28r), Stats., and s. Ins 3.39 (3) (v) and (w). Health benefit plan includes Medicare cost and select plans but does not include Medicare Advantage plans.

Ins 18.02 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 04-121: am. (1) Register June 2005 No. 594, eff. 7-1-05.

Ins 18.03 Ins 18.03 Grievances.

Ins 18.03(1) (1) Definition and explanation of the grievance procedure.

Ins 18.03(1)(a) (a) Each insurer offering a health benefit plan shall incorporate within its policies, certificates and outlines of coverage the definition of a grievance as stated in s. Ins 18.01 (4).

Ins 18.03(1)(b) (b) An insurer offering a health benefit plan shall develop an internal grievance and expedited grievance procedure that shall be described in each policy and certificate issued to insureds at the time of enrollment or issuance.

Ins 18.03(1)(c) (c) In accordance with s. 632.83 (2) (a), Stats., an insurer that offers a health benefit plan shall investigate each grievance.

Ins 18.03(2) (2) Notification of right to appeal determinations.

Ins 18.03(2)(a) (a) In addition to the requirements under sub. (1), each time an insurer offering a health benefit plan denies a claim or benefit or initiates disenrollment proceedings, the health benefit plan shall notify the affected insured of the right to file a grievance. For purposes of this subchapter, denial or refusal of an insured’s request of the insurer for a referral shall be considered a denial of a claim or benefit.

Ins 18.03(2)(b) (b) When notifying the insured of their right to grieve the denial, determination, or initiation of disenrollment, an insurer offering a health benefit plan shall either direct the insured to the policy or certificate section that delineates the procedure for filing a grievance or shall describe, in detail, the grievance procedure to the insured. The notification shall also state the specific reason for the denial, determination or initiation of disenrollment.

Ins 18.03(2)(c) (c)

Ins 18.03(2)(c)1. 1. An insurer offering a health benefit plan that is a defined network plan as defined in s. 609.01 (1b), Stats., other than a preferred provider plan as defined in s. 609.01 (4), Stats., shall do all of the following:

Ins 18.03(2)(c)1.a. a. Include in each contract between it and its providers, provider networks, and within each agreement governing the administration of provider services, a provision that requires the contracting entity to promptly respond to complaints and grievances filed with the insurer to facilitate resolution.

Ins 18.03(2)(c)1.b. b. Require contracted entities that subcontract for the provision of services, including subcontracts with health care providers, to incorporate within their contracts a requirement that the providers promptly respond to complaints and grievances filed with the insurer to facilitate resolution.

Ins 18.03(2)(c)1.c. c. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.

Ins 18.03(2)(c)1.d. d. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.

Ins 18.03(2)(c)2. 2. An insurer offering a health benefit plan that is a preferred provider plan as defined in s. 609.01 (4), Stats., shall do all of the following:

Ins 18.03(2)(c)2.a. a. Include in each contract between it and its providers, provider networks and within each agreement governing the administration of provider services, a provision that requires the contracting entity to promptly provide the insurer the information necessary to permit the insurer to respond to complaints or grievances described under subd. 2. c.

Ins 18.03(2)(c)2.b. b. Require contracted entities that subcontract for the provision of services, to incorporate within their contracts, including subcontracts with health care providers, a requirement that the subcontractor promptly provide the insurer with the information necessary to respond to complaints or grievances described under subd. 2. c.

Ins 18.03(2)(c)2.c. c. Include in its description of the grievance process required under sub. (1), a clear statement that an insured may submit to the insurer offering a health benefit plan a complaint or grievance relating to covered services provided by a participating health care provider.

Ins 18.03(2)(c)2.d. d. Process and respond to a complaint or grievance described under subd. 2. c.

Ins 18.03(2)(c)2.e. e. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.

Ins 18.03(2)(c)2.f. f. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.

Ins 18.03(2)(d) (d) If the insurer offering a health benefit plan is either a health maintenance organization as defined in s. 609.01 (2), Stats., or a limited service health organization as defined by s. 609.01 (3), Stats., and the insurer initiates disenrollment proceedings, the insurer shall additionally comply with s. Ins 9.39.

Ins 18.03(3) (3) Grievance procedure. The grievance procedure utilized by an insurer offering a health benefit plan shall include all of the following:

Ins 18.03(3)(a) (a) A method whereby the insured who filed the grievance, or the insured’s authorized representative, has the right to appear in person before the grievance panel to present written or oral information. The insurer shall permit the grievant to submit written questions to the person or persons responsible for making the determination that resulted in the denial, determination, or initiation of disenrollment unless the insurer permits the insured or insured’s authorized representative to meet with and question the decision maker or makers.

Ins 18.03(3)(b) (b) A written notification to the insured of the time and place of the grievance meeting at least 7 calendar days before the meeting.

Ins 18.03(3)(c) (c) Reasonable accommodations to allow the insured, or the insured’s authorized representative, to participate in the meeting.

Ins 18.03(3)(d) (d) The grievance panel shall comply with the requirements of s. 632.83 (3) (b), Stats., and shall not include the person who ultimately made the initial determination. If the panel consists of at least three persons, the panel may then include no more than one subordinate of the person who ultimately made the initial determination. The panel may, however, consult with the ultimate initial decision-maker.

Ins 18.03(3)(e) (e) The insured member of the panel shall not be an employee of the plan, to the extent possible.

Ins 18.03(3)(f) (f) Consultation with a licensed health care provider with expertise in the field relating to the grievance, if appropriate.

Ins 18.03(3)(g) (g) The panel’s written decision to the insured as described in s. 632.83 (3) (d), Stats., shall be signed by one voting member of the panel and include a written description of position titles of panel members involved in making the decision.

Ins 18.03(4) (4) Receipt of grievance acknowledgment. An insurer offering a health benefit plan shall, within 5 business days of receipt of a grievance, deliver or deposit in the mail a written acknowledgment to the insured or the insured’s authorized representative confirming receipt of the grievance.

Ins 18.03(5) (5) Authorization for release of information.

Ins 18.03(5)(a) (a) An insurer offering a health benefit plan may require a written expression of authorization for representation from a person acting as the insured’s authorized representative unless any of the following applies:

Ins 18.03(5)(a)1. 1. The person is authorized by law to act on behalf of the insured.

Ins 18.03(5)(a)2. 2. The insured is unable to give consent and the person is a spouse, family member or the treating provider.

Ins 18.03(5)(a)3. 3. The grievance is an expedited grievance and the person represents that the insured has verbally given authorization to represent the insured.

Ins 18.03(5)(b) (b) An insurer offering a health benefit plan shall process a grievance without requiring written authorization unless the insurer, in its acknowledgement to the person under sub. (4), clearly and prominently does all of the following:

Ins 18.03(5)(b)1. 1. Notifies the person that, unless an exception under par. (a) applies, the grievance will not be processed until the insurer receives a written authorization.

Ins 18.03(5)(b)2. 2. Requests written authorization from the person.

Ins 18.03(5)(b)3. 3. Provides the person with a form the insured may use to give written authorization. An insured may, but is not required to, use the insurer’s form to give written authorization.

Ins 18.03(5)(c) (c) An insurer offering a health benefit plan shall accept under par. (a) any written expression of authorization without requiring specific form, language or format.

Ins 18.03(5)(d) (d) An insurer offering a health benefit plan shall include in its acknowledgement of receipt of a grievance filed by an authorized representative a clear and prominent notice that health care information or medical records may be disclosed only if permitted by law. The acknowledgement shall state that unless otherwise permitted under applicable law, including the Health Insurance Portability and Accountability Act of 1996, U.S. PL 104-191, ss. 51.30, 146.82 to 146.84, and 610.70, Stats., and ch. Ins 25, informed consent is required and the acknowledgement shall include an informed consent form for that purpose. An insurer offering a health benefit plan may withhold health care information or medical records from an authorized representative, including information contained in its resolution of the grievance, but only if disclosure is prohibited by law. An insurer offering a health benefit plan shall process a grievance submitted by an authorized representative regardless of whether health care information or medical records may be disclosed to the authorized representative under applicable law.

Ins 18.03(6) (6) Resolution of a grievance. An insurer offering a health benefit plan shall resolve a grievance:

Ins 18.03(6)(a) (a) For a grievance that is a review of a benefit determination that is subject to 29 CFR 2560.503-1, within the time provided under 29 CFR 2560-503-1 (i).

Ins 18.03(6)(b) (b) For any grievance not subject to par. (a), within 30 calendar days of receiving the grievance. If the insurer offering a health benefit plan is unable to resolve the grievance within 30 calendar days, the time period may be extended an additional 30 calendar days, if the insurer provides a written notification to the insured and the insured’s authorized representative, if applicable, of all of the following:

Ins 18.03(6)(b)1. 1. That the insurer has not resolved the grievance.

Ins 18.03(6)(b)2. 2. When resolution of the grievance may be expected.

Ins 18.03(6)(b)3. 3. The reason additional time is needed.

Ins 18.03(7) (7) Commissioner annual report. The commissioner shall by June 1 of each year prepare a report that summarizes grievance experience reports received by the commissioner from insurers offering health benefit plans. The report shall also summarize OCI complaints involving the insurer offering health benefit plans that were received by the office during the previous calendar year.

Ins 18.03 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; corrections in (2) (c) 1. and (5) (d) made under s. 13.93 (2m) (b) 7., Stats., Register December 2004 No. 588; CR 05-059: am. (2) (c) 1. Register February 2006 No. 602, eff. 3-1-06.

Ins 18.04 Ins 18.04 Right of the commissioner to request OCI complaints be handled as grievances. The commissioner may require an insurer offering a health benefit plan to treat and process an OCI complaint as a grievance as appropriate, if the commissioner provides a written description of the complaint to the insurer. The insurer shall process the OCI complaint as a grievance in compliance with s. Ins 18.03.

Ins 18.04 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01.

Ins 18.05 Ins 18.05 Expedited grievance procedure. Section Ins 18.03 (2) to (4) and (6) does not apply to expedited grievances. For these situations, an insurer offering a health benefit plan shall develop a separate expedited grievance procedure. An expedited grievance shall be resolved as expeditiously as the insured’s health condition requires but not more than 72 hours after receipt of the grievance. An insurer offering a health benefit plan, upon written request, shall mail or electronically mail a copy of the insured’s complete policy to the insured or the insured’s authorized representative as expeditiously as the grievance is handled.

Ins 18.05 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-011; CR 10-023: am. Register September 2010 No. 657, eff. 10-1-10.

Ins 18.06 Ins 18.06 Reporting requirements. An insurer offering a health benefit plan shall comply with all of the following requirements:

Ins 18.06(1) (1) Each record of each complaint and grievance submitted to the insurer shall be kept and retained for a period of at least 3 years. These records shall be maintained at the insurer’s home or principal office and shall be available for review during examinations by or on request of the commissioner or office.

Ins 18.06(2) (2) Submit a grievance experience report required by s. 632.83 (2) (c), Stats., to the commissioner by March 1 of each year. The report shall provide information on all grievances received during the previous calendar year. The report shall be in a form prescribed by the commissioner and, at a minimum, shall classify grievances into the following categories:

Ins 18.06(2)(a) (a) Plan administration including plan marketing, policyholder service, billing, underwriting and similar administrative functions.

Ins 18.06(2)(b) (b) Benefit services including denial of a benefit, denial of experimental treatment, quality of care, refusal to refer insureds or to provide requested services.

Ins 18.06 Note Note: A copy of the grievance experience report form OCI26-007, required under par. (2), may be obtained from the Office of the Commissioner of Insurance, P. O. Box 7873, Madison WI 53707-7873.

Ins 18.06 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01.

subch. III of ch. Ins 18 Subchapter III — Independent Review Procedures

Ins 18.10 Ins 18.10 Definitions. In addition to the definitions in s. 632.835 (1), Stats., in this subchapter:

Ins 18.10(1) (1) “Adverse determination” has the meaning as defined in s. 632.835 (1) (a), Stats. This includes the denial of a request for a referral for out-of-network services when the insured requests health care services from a provider that does not participate in the insurer’s provider network because the clinical expertise of the provider may be medically necessary for treatment of the insured’s medical condition and that expertise is not available in the insurer’s provider network.

Ins 18.10(2) (2) “Experimental treatment determination” means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply: