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.