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.

Ins 18.12(1)(e)7. 7. 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), as appropriate.

Ins 18.12(1)(e)8. 8. Legal basis, as appropriate.

Ins 18.12(1)(f) (f) Procedures for consideration of pertinent information for cases referred to the independent review organization regarding experimental treatment determinations including all information required in par. (e) and existing medical or scientific evidence regarding the proposed treatment with respect to effectiveness and efficacy.

Ins 18.12(1)(g) (g) Policies and procedures to request and accept any additional information that may assist in rendering a determination. Information received by the independent review organization from the insured or attending provider shall be provided to the insurer offering a health benefit plan in order to provide the insurer with the opportunity to reverse its decision.

Ins 18.12(1)(h) (h) Procedures to ensure that within 2 business days of rendering a determination, the independent review organization shall, in addition to the requirements of s. 632.835 (3) (f), Stats., send to the insurer offering a health benefit plan, the insured, or the insured’s authorized representative a written notice of the determination that includes all of the following:

Ins 18.12(1)(h)1. 1. The question or issue that was referred for review.

Ins 18.12(1)(h)2. 2. A description of the qualifications of the reviewer or reviewers.

Ins 18.12(1)(h)3. 3. A clinical rationale or explanation for the independent review organization’s determination, including supporting evidence and a clear statement of the decision.

Ins 18.12(1)(h)4. 4. The decision shall be signed by the case reviewer or, in cases where more than one reviewer is assigned to review the case, the signature of at least one of the reviewers.

Ins 18.12(1)(i) (i) Procedures to ensure expedited reviews are completed in accordance with s. 632.835 (3) (g), Stats., and take into account the insured’s health condition. Upon completion of the review, the independent review organization shall provide its decision within one hour, or as expeditiously as practicable, to the insured, or the insured’s authorized representative, and the insurer.

Ins 18.12(1)(j) (j) Procedures to ensure that the decision of the independent review organization is consistent with s. 632.835 (3m), Stats.

Ins 18.12(1)(k) (k) Procedures for determining when the inclusion of an attorney or actuary as a member of a review panel or the advice of an attorney and actuary would provide appropriate and necessary assistance in the review.

Ins 18.12(2) (2) Quality assurance procedures. Independent review organizations shall establish, maintain and demonstrate compliance with written quality assurance procedures that promote objective and systematic monitoring and evaluation of the independent review process and that includes, at a minimum, all procedures to ensure the following:

Ins 18.12(2)(a) (a) That the independent reviews are conducted within the specified time frames and that required notices are provided in a timely manner.

Ins 18.12(2)(b) (b) That the selection of qualified and impartial clinical peer reviewers to conduct independent reviews on behalf of the independent review organization is achieved, including that the matching of reviewers to specific cases is suitable.

Ins 18.12(2)(c) (c) The independent review organization shall conduct appropriate training, monitor performance on an ongoing basis and evaluate, no less than annually, each of the reviewers and non-clinical staff.

Ins 18.12(2)(d) (d) That the confidentiality of personal medical information is maintained in accordance with state and federal law. Access to personal medical information shall be limited to only the information necessary for review of the services under independent review, used solely for the purpose of independent review and shared only with the selected reviewers, the insurer and the insured or the insured’s authorized representative.

Ins 18.12(2)(e) (e) That any person employed by, or under contract with, the independent review organization adheres to the requirements of this section.

Ins 18.12(2)(f) (f) That management reports are adequate to track and monitor matters described in pars. (a) to (e).

Ins 18.12(3) (3) Accessibility.

Ins 18.12(3)(a) (a) The independent review organization shall establish a toll-free telephone service to receive information on a 24-hour, 7-days per week, basis. The telephone service selected shall be capable of accepting, recording or providing appropriate instruction to incoming telephone callers during other than normal business hours.

Ins 18.12(3)(b) (b) The independent review organization shall establish policies and procedures to ensure that services are provided during times other than normal business hours to ensure that the independent review organization meets its obligation under sub. (1) (i).