Chapter Ins 18

Chapter Ins 18

HEALTH BENEFIT PLAN GRIEVANCES AND INDEPENDENT REVIEW ORGANIZATIONS CERTIFICATION AND REVIEW PROCEDURES

Subchapter I — Definitions

Ins 18.01   Definitions.

Subchapter II — Grievance Procedures

Ins 18.02   Definitions.

Ins 18.03   Grievances.

Ins 18.04   Right of the commissioner to request OCI complaints be handled as grievances.

Ins 18.05   Expedited grievance procedure.

Ins 18.06   Reporting requirements.

Subchapter III — Independent Review Procedures

Ins 18.10   Definitions.

Ins 18.105   Annual CPI adjustment for independent review eligibility.

Ins 18.11   Independent review.

Ins 18.12   Independent review organization procedures.

Ins 18.13   Standards of independent review.

Ins 18.14   Approval of independent review organizations.

Ins 18.16   Independent review organization reporting requirements.

Ins 18.18   Independent review organization fees.

subch. I of ch. Ins 18 Subchapter I — Definitions

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.