Chapter Ins 18

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.

Ins 18.11(2) (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:

Ins 18.11(2)(a) (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:

Ins 18.11(2)(a)2. 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.

Ins 18.11(2)(a)3. 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.

Ins 18.11 Note 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.

Ins 18.11(2)(a)4. 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.

Ins 18.11(2)(a)5. 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.

Ins 18.11(2)(a)6. 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:

Ins 18.11(2)(a)6.a. 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.

Ins 18.11(2)(a)6.b. 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.

Ins 18.11(2)(a)7. 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.

Ins 18.11(2)(b) (b)

Ins 18.11(2)(b)1. 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.

Ins 18.11(2)(b)2. 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.

Ins 18.11(3) (3) Independent review timeframes. In addition to the requirements set forth in s. 632.835 (3), Stats., the following procedures shall be followed:

Ins 18.11(3)(a) (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.

Ins 18.11(3)(b) (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.

Ins 18.11(3)(bm) (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.

Ins 18.11(3)(c) (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.

Ins 18.11(3)(d) (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.

Ins 18.11(4) (4) Disputes.

Ins 18.11(4)(a) (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.

Ins 18.11(4)(b) (b) Disputes that are related to administrative matters, including enrollment eligibility, not related to treatment or services are not eligible for independent review determinations.

Ins 18.11 History History: 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.

Ins 18.12 Ins 18.12 Independent review organization procedures.

Ins 18.12(1) (1) Independent review organizations shall have, and demonstrate compliance with, written policies and procedures governing all aspects of both the standard review and expedited review processes as described in s. 632.835, Stats., including all of the following:

Ins 18.12(1)(a) (a) A regulatory compliance program that does all of the following:

Ins 18.12(1)(a)1. 1. Tracks applicable independent review laws and regulations.

Ins 18.12(1)(a)2. 2. Ensures the organization’s compliance with applicable laws.

Ins 18.12(1)(a)3. 3. Maintains a current list of potential conflicts of interest updated on no less than a quarterly basis in addition to conducting a conflict review at the time of each case referral to the organization.

Ins 18.12(1)(b) (b) A procedure to determine, upon receipt of the referral for review, all of the following:

Ins 18.12(1)(b)1. 1. Whether a conflict of interest exists. If a conflict exists, the independent review organization shall provide a written notification to the insurer, the commissioner and the insured, or the insured’s authorized representative, within 3 business days stating that a conflict exists and declining to take the review, indicating that a different independent review organization will need to be selected by the insured, or the insured’s authorized representative.

Ins 18.12(1)(b)2. 2. The type of case for which review is sought. The independent review organization shall determine if the case relates to a coverage denial determination or an administrative issue. If the independent review organization determines that the review is not related to a coverage denial determination, the independent review organization shall provide written notification to the commissioner, the insured, or the insured’s authorized representative, and the insurer of its determination within 2 business days.

Ins 18.12(1)(b)3. 3. The specific question or issue that is to be resolved by the independent review process.

Ins 18.12(1)(b)4. 4. Whether the amount published in accordance with s. Ins 18.105, has been met based upon the type of determination the insurer made. The independent review organization shall calculate the amount that is required to be met, in accordance with s. 632.835 (1) (a) 4. and (b) 4., Stats., and s. Ins 18.10 (2) (d), as adjusted in accordance with s. 632.835 (5) (c), Stats., and s. Ins 18.105, using the actual cost charged the insured without deduction for cost sharing or contractual agreements with providers.

Ins 18.12(1)(b)5. 5. Whether the case merits standard review or expedited review.

Ins 18.12(1)(c) (c) Criteria for the number and qualification of reviewers. The criteria must meet the requirements of sub. (4).

Ins 18.12(1)(d) (d) Procedures to ensure that, upon selection of the reviewer, a file which includes all information necessary to consider the case is provided to the reviewer. In cases where more than one reviewer is assigned to the case by the independent review organization, the independent review organization shall provide an opportunity for the reviewers to discuss the case with one another and shall accept the majority decision of the reviewers.

Ins 18.12(1)(e) (e) Procedures for consideration of pertinent information for cases referred to independent review organizations regarding an adverse determination, including all of the following:

Ins 18.12(1)(e)1. 1. The insured’s medical records.

Ins 18.12(1)(e)2. 2. The attending provider’s recommendation.

Ins 18.12(1)(e)3. 3. The terms of coverage under the insured’s health benefit plan.

Ins 18.12(1)(e)4. 4. Information accumulated regarding the case prior to its referral to independent review, including the rationale for prior review determinations.

Ins 18.12(1)(e)5. 5. Information submitted to the independent review organization by the referring entity, insured or attending provider.

Ins 18.12(1)(e)6. 6. Clinical review criteria developed and used by the insurer.

Ins 18.12(1)(e)7. 7. Medical or scientific evidence including evidence that is determined to be an efficacious treatment or strategy as defined at s. Ins 3.36 (3) (c), as appropriate.

Ins 18.12(1)(e)8. 8. Legal basis, as appropriate.

Ins 18.12(1)(f) (f) Procedures for consideration of pertinent information for cases referred to the independent review organization regarding experimental treatment determinations including all information required in par. (e) and existing medical or scientific evidence regarding the proposed treatment with respect to effectiveness and efficacy.

Ins 18.12(1)(g) (g) Policies and procedures to request and accept any additional information that may assist in rendering a determination. Information received by the independent review organization from the insured or attending provider shall be provided to the insurer offering a health benefit plan in order to provide the insurer with the opportunity to reverse its decision.

Ins 18.12(1)(h) (h) Procedures to ensure that within 2 business days of rendering a determination, the independent review organization shall, in addition to the requirements of s. 632.835 (3) (f), Stats., send to the insurer offering a health benefit plan, the insured, or the insured’s authorized representative a written notice of the determination that includes all of the following:

Ins 18.12(1)(h)1. 1. The question or issue that was referred for review.

Ins 18.12(1)(h)2. 2. A description of the qualifications of the reviewer or reviewers.

Ins 18.12(1)(h)3. 3. A clinical rationale or explanation for the independent review organization’s determination, including supporting evidence and a clear statement of the decision.

Ins 18.12(1)(h)4. 4. The decision shall be signed by the case reviewer or, in cases where more than one reviewer is assigned to review the case, the signature of at least one of the reviewers.

Ins 18.12(1)(i) (i) Procedures to ensure expedited reviews are completed in accordance with s. 632.835 (3) (g), Stats., and take into account the insured’s health condition. Upon completion of the review, the independent review organization shall provide its decision within one hour, or as expeditiously as practicable, to the insured, or the insured’s authorized representative, and the insurer.

Ins 18.12(1)(j) (j) Procedures to ensure that the decision of the independent review organization is consistent with s. 632.835 (3m), Stats.

Ins 18.12(1)(k) (k) Procedures for determining when the inclusion of an attorney or actuary as a member of a review panel or the advice of an attorney and actuary would provide appropriate and necessary assistance in the review.

Ins 18.12(2) (2) Quality assurance procedures. Independent review organizations shall establish, maintain and demonstrate compliance with written quality assurance procedures that promote objective and systematic monitoring and evaluation of the independent review process and that includes, at a minimum, all procedures to ensure the following:

Ins 18.12(2)(a) (a) That the independent reviews are conducted within the specified time frames and that required notices are provided in a timely manner.

Ins 18.12(2)(b) (b) That the selection of qualified and impartial clinical peer reviewers to conduct independent reviews on behalf of the independent review organization is achieved, including that the matching of reviewers to specific cases is suitable.

Ins 18.12(2)(c) (c) The independent review organization shall conduct appropriate training, monitor performance on an ongoing basis and evaluate, no less than annually, each of the reviewers and non-clinical staff.

Ins 18.12(2)(d) (d) That the confidentiality of personal medical information is maintained in accordance with state and federal law. Access to personal medical information shall be limited to only the information necessary for review of the services under independent review, used solely for the purpose of independent review and shared only with the selected reviewers, the insurer and the insured or the insured’s authorized representative.

Ins 18.12(2)(e) (e) That any person employed by, or under contract with, the independent review organization adheres to the requirements of this section.

Ins 18.12(2)(f) (f) That management reports are adequate to track and monitor matters described in pars. (a) to (e).

Ins 18.12(3) (3) Accessibility.

Ins 18.12(3)(a) (a) The independent review organization shall establish a toll-free telephone service to receive information on a 24-hour, 7-days per week, basis. The telephone service selected shall be capable of accepting, recording or providing appropriate instruction to incoming telephone callers during other than normal business hours.

Ins 18.12(3)(b) (b) The independent review organization shall establish policies and procedures to ensure that services are provided during times other than normal business hours to ensure that the independent review organization meets its obligation under sub. (1) (i).

Ins 18.12(4) (4) Reviewer qualifications.

Ins 18.12(4)(a) (a) In addition to the requirements of s. 632.835 (6m), Stats., the independent review organization shall require all clinical peer reviewers assigned to conduct independent reviews to be physicians or other appropriate health care providers whose qualifications are verified at least every 2 years.

Ins 18.12(4)(b) (b) For coverage denial determinations that include a legal review, the independent review organization shall require legal reviewers assigned to conduct independent reviews be attorneys licensed and in good standing in this state and whose qualifications are verified at least every 2 years.

Ins 18.12(4)(c) (c) For coverage denial determinations that include review of an underwriting determination, the independent review organization shall require actuaries be assigned to assist in the review and be a member in good standing of the American academy of actuaries and whose qualifications are verified at least every 2 years.

Ins 18.12(5) (5) Conflict of interest. In addition to the requirements in s. 632.835 (6), Stats., all clinical peer, legal and actuary reviewers shall, at least quarterly, provide to the independent review organization a list of potential conflicts of interest.

Ins 18.12(6) (6) Director.

Ins 18.12(6)(a) (a) Except as provided in par. (b), an independent review organization shall employ or contract with a medical director with professional post-residency experience in direct patient care who holds a current license to practice medicine and who has a clinical specialty appropriate to the type of reviews conducted by the independent review organization.

Ins 18.12(6)(b) (b) An independent review organization that limits its reviews to matters related to a particular type of health care may employ or contract with a clinical director. The clinical director shall be trained and hold a current license in a medical or health care specialty appropriate to the full scope of the organization’s review.

Ins 18.12(6)(c) (c) The independent review organization shall require the medical director or clinical director to oversee the medical or health care aspects of quality assurance and credentialing programs.

Ins 18.12(6m) (6m) An independent review organization may employ or contract with a law firm, experienced attorney, actuarial entity or experienced actuary to assist in the review of matters related to reformations, rescissions and preexisting condition denial determinations. The independent review organization shall oversee aspects of quality assurance, licensing and expertise of the legal or actuarial reviewer.

Ins 18.12(7) (7) Delegated functions. The independent review organization may delegate or subcontract review functions. Nevertheless, the independent review organization is responsible for the delegated or subcontracted functions, including any violation of law, policy or procedure. In addition, an independent review organization that delegates or subcontracts independent review functions shall provide documentation and verification of all of the following:

Ins 18.12(7)(a) (a) Written contracts with the subcontractor that delineates with specificity all duties and responsibilities.

Ins 18.12(7)(b) (b) A review by the independent review organization, on at least an annual basis, of the subcontractor’s policies, procedures, and quality assurance program, if relevant to the subcontracted functions.

Ins 18.12(7)(c) (c) A review by the independent review organization, on at least an annual basis, of the subcontractor’s performance and compliance, monitored by the independent review organization, with stated policies, procedures, quality assurance programs and applicable laws.

Ins 18.12(7)(d) (d) A review by the independent review organization, on at least an annual basis, of the effectiveness of communication and coordination of processes between the independent review organization and the subcontractor.

Ins 18.12(8) (8) Unbiased. An independent review organization shall be unbiased. An independent review organization shall establish and maintain procedures to ensure that it is unbiased.

Ins 18.12 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 04-079: am. (1) (b) Register December 2004 No. 588, eff. 1-1-05; CR 10-023: am. (1) (b) 1., 2., (e) 7., (4), (5), cr. (1) (e) 8., (k), (6m) Register September 2010 No. 657, eff. 10-1-10.

Ins 18.13 Ins 18.13 Standards of independent review.

Ins 18.13(1) (1) For coverage denial determinations other than experimental treatment determinations, independent review organizations shall consider any of the following: