Chapter Ins 18

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:

Ins 18.10(2)(a) (a) A proposed treatment has been reviewed.

Ins 18.10(2)(b) (b) Based on the information provided, the treatment under par. (a) is determined to be experimental under the terms of the health benefit plan.

Ins 18.10(2)(c) (c) Based on the information provided, the insurer that issued the health benefit plan denied the treatment under par. (a) or payment for the treatment under par. (a).

Ins 18.10(2)(d) (d) Pursuant to s. 632.835 (5) (c), Stats., the cost or expected cost of the denied treatment or payment exceeds, or will exceed during the course of the treatment, the amount published in accordance with s. Ins 18.105.

Ins 18.10(3) (3) “Health benefit plan” has the meaning provided in s. 632.835 (1) (c), Stats., and includes Medicare supplement and 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 18.10(4) (4) “Medical or scientific evidence” means information from any of the following sources:

Ins 18.10(4)(a) (a) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.

Ins 18.10(4)(b) (b) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health’s Library of Medicine for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline and MEDLARS database Health Services Technology Assessment Research (HSTAR).

Ins 18.10(4)(c) (c) Medical journals recognized by the Secretary of Health and Human Services under 42 USC1320c et. seq. of the federal Social Security Act.

Ins 18.10(4)(d) (d) Any of the following standard reference compendia most current edition in publication at the time of the dispute:

Ins 18.10(4)(d)1. 1. The American Hospital Formulary Service — Drug Information.

Ins 18.10(4)(d)2. 2. The Center for Drug Evaluation and Research History.

Ins 18.10(4)(d)3. 3. The ADA/PDR Guide to Dental Therapeutics, current edition.

Ins 18.10(4)(d)4. 4. The United States Pharmacopeia — National Formulary.

Ins 18.10(4)(e) (e) Findings, studies or research conducted by, or under the auspices of, federal governmental agencies and nationally recognized federal research institutes, including:

Ins 18.10(4)(e)1. 1. The federal Agency for Healthcare Research and Quality.

Ins 18.10(4)(e)2. 2. The National Institutes of Health.

Ins 18.10(4)(e)3. 3. The National Cancer Institute.

Ins 18.10(4)(e)4. 4. The National Academy of Sciences.

Ins 18.10(4)(e)5. 5. The Health Care Financing Administration.

Ins 18.10(4)(e)6. 6. Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services.

Ins 18.10(4)(e)7. 7. Any other medical or scientific evidence that is comparable to the sources listed in this paragraph.

Ins 18.10(4e) (4e) “Preexisting condition exclusion denial determination” has the meaning as defined in s. 632.835 (1) (cm), Stats.

Ins 18.10(4m) (4m) “Legal basis” means information from any of the following sources:

Ins 18.10(4m)(a) (a) The most current version of The American Journal of Jurisprudence.

Ins 18.10(4m)(b) (b) United States 7th Judicial Circuit Court decisions.

Ins 18.10(4m)(c) (c) Wisconsin statutory and common law.

Ins 18.10(4m)(d) (d) The terms of the insurance contract applicable for the period of coverage in dispute.

Ins 18.10(5) (5) “Unbiased” means an independent review organization that complies with all of the following:

Ins 18.10(5)(a) (a) Section 632.835 (6), Stats.

Ins 18.10(5)(b) (b) The independent review organization does not provide incentives of any kind, including financial incentives, to providers or consumers as inducements for selection as the independent review organization.

Ins 18.10(5)(c) (c) The independent review organization does not directly or indirectly receive any compensation, in any form, related to a review, other than the compensation permitted under this subchapter and s. 632.835, Stats.

Ins 18.10(5)(d) (d) The independent review organization does not promote, to providers, consumers or insurers any of the following:

Ins 18.10(5)(d)1. 1. A pattern of favorable results or a pattern of favorable results on a particular treatment or subject.

Ins 18.10(5)(d)2. 2. An association with a class of providers, consumers or insurers.

Ins 18.10(5)(d)3. 3. A bias favorable to a class of providers, consumers or insurers.

Ins 18.10(5)(e) (e) The independent review organization does not have a pattern of decisions that are unsupported by substantial evidence.

Ins 18.10 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 04-079: am. (2) (d) Register December 2004 No. 588, eff. 1-1-05; CR 04-121: am. (3) Register June 2005 No. 594, eff. 7-1-05; CR 10-023: am. (4) (d), cr. (4e) and (4m) Register September 2010 No. 657, eff. 10-1-10.

Ins 18.105 Ins 18.105 Annual CPI adjustment for independent review eligibility.

Ins 18.105(1) (1) Publication and effective date. The commissioner shall publish to the office of the commissioner of insurance website on or before December 1 of each year the consumer price index for urban consumers as determined by the U.S. Department of Labor and publish the adjusted dollar amount in accordance with s. 632.835 (5) (c), Stats. The adjusted dollar amount published each December shall be used by insurers offering health benefit plans when complying with s. Ins 18.10 (2) (d) and s. 632.835 (1) (a) 4., Stats., effective the following January 1.

Ins 18.105(2) (2) Determination of adjusted rates. Insurers offering health benefit plans shall apply the adjusted dollar amount published annually by the commissioner that is required to be met in accordance with s. 632.835 (1) (a) 4. and (b) 4., Stats., as follows:

Ins 18.105(2)(a) (a) For adverse determinations when treatment was received by the insured, the insurer shall use the date treatment was received to determine the proper adjusted dollar amount that is required to be met in accordance with s. 632.835 (1) (a) 4., Stats.

Ins 18.105(2)(b) (b) For adverse determinations when a course of treatment was received by the insured or terminated by the insurer, the insurer shall use later of the following dates to determine the proper adjusted dollar amount that is required to be met in accordance with s. 632.835 (1) (a) 4., Stats.:

Ins 18.105(2)(b)1. 1. The last date treatment was received by the insured; or,

Ins 18.105(2)(b)2. 2. The date the insurer mailed written notification to the insured, or the insured’s authorized representative, that the course of treatment was terminated or denied.

Ins 18.105(2)(c) (c) For experimental treatment determinations the insurer shall use the date the insurer mailed written notification to the insured, or the insured’s authorized representative, that for the proposed treatment the insurer has either denied the treatment or denied payment for the treatment, to determine the proper adjusted dollar amount that is required to be met in accordance with s. 632.835 (1) (b) 4., Stats., and s. Ins 18.10 (2) (d).

Ins 18.105 Note Note: Office website address: http://oci.wi.gov.

Ins 18.105 History History: CR 04-079: cr. Register December 2004 No. 588, eff. 1-1-05.

Ins 18.11 Ins 18.11 Independent review.

Ins 18.11(1) (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.