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.