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: Ins 18.03(2)(c)2.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 provide the insurer the information necessary to permit the insurer to respond to complaints or grievances described under subd. 2. c. Ins 18.03(2)(c)2.b.b. Require contracted entities that subcontract for the provision of services, to incorporate within their contracts, including subcontracts with health care providers, a requirement that the subcontractor promptly provide the insurer with the information necessary to respond to complaints or grievances described under subd. 2. c. Ins 18.03(2)(c)2.c.c. Include in its description of the grievance process required under sub. (1), a clear statement that an insured may submit to the insurer offering a health benefit plan a complaint or grievance relating to covered services provided by a participating health care provider. Ins 18.03(2)(c)2.e.e. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph. Ins 18.03(2)(c)2.f.f. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph. Ins 18.03(2)(d)(d) If the insurer offering a health benefit plan is either a health maintenance organization as defined in s. 609.01 (2), Stats., or a limited service health organization as defined by s. 609.01 (3), Stats., and the insurer initiates disenrollment proceedings, the insurer shall additionally comply with s. Ins 9.39. Ins 18.03(3)(3) Grievance procedure. The grievance procedure utilized by an insurer offering a health benefit plan shall include all of the following: Ins 18.03(3)(a)(a) A method whereby the insured who filed the grievance, or the insured’s authorized representative, has the right to appear in person before the grievance panel to present written or oral information. The insurer shall permit the grievant to submit written questions to the person or persons responsible for making the determination that resulted in the denial, determination, or initiation of disenrollment unless the insurer permits the insured or insured’s authorized representative to meet with and question the decision maker or makers. Ins 18.03(3)(b)(b) A written notification to the insured of the time and place of the grievance meeting at least 7 calendar days before the meeting. Ins 18.03(3)(c)(c) Reasonable accommodations to allow the insured, or the insured’s authorized representative, to participate in the meeting.