Chapter Ins 18

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:

Ins 18.13(1)(a) (a) 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).

Ins 18.13(1)(b) (b) Legal basis.

Ins 18.13(1)(c) (c) The applicable insurance contract.

Ins 18.13(2) (2) Independent review organizations shall include as members or advisors an attorney or actuary when the dispute involves a rescission, reformation or the dispute includes a legal dispute. The addition of an attorney or actuary to a review panel is at the discretion of the independent review organization or reviewers and need only be considered when the independent review organization or reviewers determine additional expertise would provide appropriate and necessary assistance in the review.

Ins 18.13 History History: CR 10-023: cr. Register September 2010 No. 657, eff. 10-1-10.

Ins 18.14 Ins 18.14 Approval of independent review organizations.

Ins 18.14(1) (1) In addition to meeting the requirements established s. 632.835 (4) (a), Stats., any independent review organization seeking approval to conduct independent reviews shall submit an application for approval on a form prescribed by the commissioner and include with the form all documentation and information necessary for the commissioner to determine if the independent review organization is unbiased and satisfies s. Ins 18.12.

Ins 18.14(2) (2) The independent review organization shall submit informational materials to the commissioner as part of the application. Materials will be maintained in the office for public review.

Ins 18.14(3) (3) The independent review organization shall submit the application fee in accordance with s. 601.31 (1) (Lp), Stats., at the time of the application to an identified lock box address.

Ins 18.14 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01.

Ins 18.16 Ins 18.16 Independent review organization reporting requirements.

Ins 18.16(1) (1) An independent review organization shall maintain records on all independent review activity during each calendar year and submit a report to the commissioner, on a form prescribed by the commissioner, by March 1 of each year for the prior calendar year’s experience. Records shall be maintained so that, at a minimum, they satisfy the reporting requirements to the commissioner and shall be retained for at least 3 years.

Ins 18.16(2) (2) The annual report shall include all of the following information on an aggregate basis, by insurer and by insurer and insurance product name:

Ins 18.16(2)(a) (a) The total number of requests for independent review received.

Ins 18.16(2)(b) (b) The total number of requests for independent review declined and the reason for the declination, including whether the request was a qualified request or within the scope of the health benefit plan policy.

Ins 18.16(2)(c) (c) The total number of requests for expedited independent review that the independent review organization declined to handle in an expedited timeframe, including whether the request was a qualified request or within the scope of the health benefit plan policy.

Ins 18.16(2)(d) (d) The number of independent reviews that were done in an expedited manner and the results of those reviews.

Ins 18.16(2)(e) (e) The number of requests for independent review resolved and, of those resolved, the number resolved upholding the coverage denial determination by the insurer and the number resolved reversing the coverage denial determination by the insurer.

Ins 18.16(2)(em) (em) The names and specialty of the reviewers participating in reviews conducted during the year. The listing shall include the name of any attorney or actuary or the respective firm, who participated in the reviews.

Ins 18.16(2)(f) (f) The average length of time for resolution.

Ins 18.16(2)(g) (g) A detailed summary of cases including a synopsis of facts, rationale for decision and key evidence relied upon to reach the reviewer’s decision. The summary shall also include the types of cases or coverage for which an independent review was sought.

Ins 18.16(2)(h) (h) The cost of reviews both in the aggregate and on a case by case basis.

Ins 18.16(2)(i) (i) The number of independent reviews that were terminated as the result of reconsideration by the insurer offering a health benefit plan of its coverage denial determination after the receipt of additional information from the insured, the insured’s authorized representative, or other appropriate sources.

Ins 18.16(2)(j) (j) Any other information the commissioner requests.

Ins 18.16 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 10-023: am. (2) (e), (i), cr. (2) (em) Register September 2010 No. 657, eff. 10-1-10.

Ins 18.18 Ins 18.18 Independent review organization fees.

Ins 18.18(1) (1) A certified independent review organization shall submit its fee schedule in accordance with s. 632.835 (4) (ap), Stats., to the commissioner for review and approval.

Ins 18.18(2) (2) Fee schedules shall be based on prevailing rates in the industry demonstrated by supporting credible documentation including actual costs for conducting the reviews. Fee schedules shall be on a per case basis according to categories established by the commissioner. The fee schedule shall include a category for the fee payable for a review that is terminated because the insurer voluntarily reverses its decision because of information first received by the insurer after the review is requested.

Ins 18.18(3) (3) An insurer offering a health benefit plan shall pay the fee submitted by the independent review organization within 30 days of receipt of a written invoice or billing record from the independent review organization.

Ins 18.18(4) (4) The independent review organization may only charge the fees in accordance with the fee schedule that is approved by the commissioner.

Ins 18.18(6) (6) If an independent review organization determines the matter is not within its authority to review, it may not charge for that determination.

Ins 18.18 History History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 10-023: r. (5), am. (6) Register September 2010 No. 657, eff. 10-1-10.