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(6)(6) “Independent review” means a review conducted by a certified independent review organization. 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 HistoryHistory: 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. Ins 18.02Ins 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 18.03(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(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)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. Ins 18.03(2)(c)1.d.d. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph. Ins 18.03(2)(c)2.2. An insurer offering a health benefit plan that is a preferred provider plan as defined in s. 609.01 (4), Stats., shall do all of the following: