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.

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.