What the statutes mean

This portion of the statutes was enacted in mid-2000 and has the potential to end many of the conflicts that exist between insurance companies and chiropractors. The conflicts are based on disputes over the “medical necessity” of care. Since the chiropractic profession has not adopted protocols for the treatment of specific conditions, the insurance industry has been free to hire chiropractors that are all too willing to adopt the restrictive attitudes of their employers.

This law can be an important benefit to patients and their chiropractors because it allows a patient to choose an independent review organization to which they can appeal the insurer’s decision. This is a valuable option; however, its value can be diminished unless the doctor and the patient are aware of the following.

Maximizing the Benefit From
Independent Review Organizations

• The credibility of the Independent Review Organizations depends on the quality of their work. They will not be in business long if they routinely deny care that should be approved or, approve care that should be denied.

• The quality of a doctor’s clinical documentation is the key to success in the review process. Clinical documentation has a different degree of credibility depending on how it was prepared. The following ranks clinical documentation from the perception of “best” to “worst”.

1. Notes dictated immediately after patient services are rendered (with or without supplementary exam forms).
2. Notes typed extemporaneously into the patient’s chart during or immediately after patient services are rendered (with or without supplementary exam forms).
3. Notes that are hand written at, or immediately after, patient services are rendered that are the basis for dictated notes prepared at a later date (with or without supplementary exam forms).
4. Notes dictated on the same day patient services are rendered (with or without supplementary exam forms.
5. Notes that are hand written at or immediately after patient services are rendered and later transcribed into typed notes (with or without supplementary exam forms).
6. Notes that are hand written at the end of the day and later transcribed into typed notes (with or without supplementary exam forms).
7. Notes that are hand written but completely legible (as determined by the insurance company) at or immediately after patient services are rendered.
8. Notes dictated a day or more after the patient received care (with or without supplementary exam forms).
9. Notes that are hand written a day or more after the patient received care and later transcribed into typed notes (with or without supplementary exam forms).
10. Computer or “wand” generated notes that are customized by the doctor.
11. Computer or “wand” generated notes based on a standard format. 12. Illegible hand written notes b An appeal to the independent review organization cannot be made until the patient/doctor has exhausted the insurer’s internal appeals/grievance procedure.

The appeal/grievance process

Insurance companies would have a much better relationship with patients and doctors if they wrote clear and concise letters explaining their reasons for rejecting care instead of using cryptic codes on their explanation of benefits. For example, it is completely unprofessional for an insurance company to state that care is not “medically necessary” when the clinical records of the doctor were never requested or reviewed.

It can be very frustrating when an unknown chiropractor, serving as the insurance companies consultant, decides that a chiropractor’s care was unnecessary. However, for some insurance companies the review process is not designed as an impartial process. These insurers only hire chiropractors to do IME’s that will support the insurance companies’ position. They are playing a numbers game. As long as a large number of chiropractors are willing to accept their decisions without a fight, it is profitable for them to do biased reviews.

Every insurance company has an appeal process. Depending on the ethics of the insurer, some almost always confirm the opinion of the original reviewer while others legitimately re-review the documentation with a different chiropractor. What is certain is that insurance companies quickly learn which chiropractors do or don’t fight their decisions. The ones that do not fight are likely to see a continuing pattern of care denials. The ones that do fight, especially those that “fight all the way,” see more of their care approved.

The law requires you to exhaust the grievance or appeal process of the insurer before you are allowed to request independent review. Since it is always to the advantage of the doctor and their patient to resolve problems quickly, the following suggestions can assist the doctor in explaining why his/her care was necessary.

– A complete copy of the clinical documentation should accompany the appeal. Some offices only send the clinical documentation related to the claims that were rejected. This is a mistake because when documentation is reviewed, the reviewer wants to start at the beginning of the case to review the results of the doctor’s examination and to make sure that the assessment and treatment plan were consistent with the objective exam findings.

– When documentation is submitted, the most effective responses include a brief narrative in which each paragraph is indexed to the comments in the IME, and/or the appropriate section of the clinical documentation.

– Without clinical documentation, or with documentation that is “canned” or illegible, the appeal is not likely to be successful.

– Along with the response, the doctor should request that file be re-reviewed and the insurer should be informed that, if the case is not resolved satisfactorily, that the patient intends to use the independent review process.

Every insurance company is required to:

¨ Provide their insureds with complete and understandable information describing their internal grievance procedure.
¨ Submit an annual report to the insurance commissioner describing the internal grievance procedure and summarizing the experience under the procedure for the year. Obtaining these reports for insurance companies for whom an office frequently files claims can give a chiropractor an understanding of how the insurer handles internal appeals.
¨ The internal grievance procedure must include all of the following elements:

• The opportunity for the patient to submit a written grievance in any form.
• The establishment of a grievance panel for the investigation of each grievance consisting of at least one individual authorized to take corrective action on the grievance and at least one insured other than the grievant, if an insured is available to serve on the grievance panel.
• Prompt investigation of each grievance.
• Notification to each grievant of the disposition of his or her grievance and of any corrective action taken on the grievance.
• Retention of records pertaining to each grievance for at least 3 years after the date of notification.

To qualify for an independent review, the amount of care in dispute must be at least $250.

Review requirements

Insurer notice: When an insurer rejects a claim because it determined the care was not “medically necessary” it must provide a notice to the insured that they have a right to an independent review. The patient is allowed to choose the review company and the insurer is required to include a current listing of independent review organizations that have been approved by the insurance commissioner.

Time Limit: A patient may not request an independent review until they have exhausted the internal grievance/appeal system of the insurer. The request for an independent review must be filed within 4 months after receiving notice that their final internal appeal was turned down.

Exceptions: A patient is not required to exhaust the internal grievance procedure before requesting an independent review if:

1) If the patient and the insurer agree that the matter may proceed directly to independent review.
2) If the independent review organization determines that the health condition of the patient is such that requiring the patient to use the internal grievance procedure would jeopardize the health of the patient or the patient’s ability to regain maximum function.

In order to qualify for this exemption, the patient must request an independent review from the insurer and a separate request to the independent review organization to bypass the internal grievance procedure. Since medical necessity questions are typically raised at the end of a patient’s treatment, it is not likely that this exemption would apply to a large number of chiropractic patients.

To request a review

1) It is expected the insurance commissioner will develop a form for the purpose of requesting an independent review.

2) The patient may request the independent review or, a doctor may do so at the request of the patient.

3) The patient and/or their doctor must indicate the independent review organization they wish to do the review in the appropriate section of the request form.

4) A fee of $25 must be included with the request. The fee is returned if the independent review organization finds in favor of the patient’s care. The insurer is responsible to pay the fee for the independent review.

5) The request form is mailed to the insurer.

6) Within 5 business days after receiving the request for independent review the insurer must submit to the independent review organization copies of all of the following:

– Any information previously submitted to the insurer by the patient or their doctor in support of the patient’s position.
– The contract provisions or evidence of coverage of the patient’s health plan.
– Any other relevant documents or information used by the insurer in the internal grievance determination. This would normally be the opinion of the insurance company reviewer.

7) Once the independent review organization receives the information from the insurance company they have 5 business days to request any additional information that it requires for the review from the patient or the insurer.

8) Within 5 business days after receiving a request for additional information from the independent review organization the patient or the insurer must submit the information or an explanation of why the information is not being submitted. If the insurer or the patient submits information to the independent review organization, they must also send a copy of that information to the other party.

9) In addition to the clinical documentation and information from the insurance company, the independent review organization may also consider any typed or printed, verifiable medical or scientific evidence that they determine is relevant, regardless of whether the evidence has been submitted for consideration at any time previously.

10) If, on the basis of any additional information, the insurer reconsiders the patient’s grievance and determines that the treatment should be covered, the independent review is terminated.

11) The independent review organization must make a decision within 30 days after all of the time limits have expired. The decision must be in writing with a copy mailed to the patient and the insurer. The decision of an independent review organization is binding on the insured and the insurer. There is no further appeal.

Neither the patient, the doctor, or the insurance company is allowed to present
their case in person before the independent review organization.

Special procedures for emergency cases

In addition to the procedures detailed above, the following special procedures apply if the independent review organization determines that the health condition of the patient is such that requiring the patient to use the internal grievance procedure would jeopardize the health of the patient or the patient’s ability to regain maximum function. Because medical necessity questions are typically raised at the end of a patient’s treatment, it is not likely that many chiropractic patients would qualify for these procedures.

1) Within 1 day after receiving the request for independent review the insurer must submit to the independent review organization copies of all of the following:

– Any information previously submitted to the insurer by the patient or their doctor in support of the patient’s position.
– The contract provisions or evidence of coverage of the patient’s health plan.
– Any other relevant documents or information used by the insurer in the internal grievance determination. This would normally be the opinion of the insurance company reviewer.

2) Once the independent review organization receives the information from the insurance company they have 2 business days to request any additional information that it requires for the review from the patient or the insurer.

3) Within 2 business days after receiving a request for additional information from the independent review organization the patient or the insurer must submit the information or an explanation of why the information is not being submitted.

4) The independent review organization must make a decision within 72 hours days after all of the time limits have expired.

Standards for decisions by the independent review organization

The decision of an independent review organization regarding the medical necessity of a patient’s care must be consistent with the terms of the patient’s health plan.

The decision of an independent review organization regarding an experimental treatment is limited to a determination of whether the proposed treatment is experimental. The independent review organization must determine that the treatment is not experimental and find in favor of the patient only if the independent review organization finds all of the following:

a The treatment has been approved by the federal food and drug administration, if the treatment is subject to the approval of the federal food and drug administration.
a Medically and scientifically accepted evidence clearly demonstrates that the treatment meets all of the following criteria:

– The treatment is proven safe.
– The treatment can be expected to produce greater benefits than the standard treatment without posing a greater adverse risk to the insured.
– The treatment meets the coverage terms of the health benefit plan and is not specifically excluded under the terms of the health benefit plan.

Certification of independent review organizations

The insurance commissioner has the responsibility to certify independent review organizations. An independent review organization must demonstrate to the satisfaction of the commissioner that it is unbiased, as defined by the insurance commissioner’s rules. Once on organization is certified it must be re-certified every 2 years.

Independent review organizations must have a quality assurance policy to ensure:

• the timeliness and quality of their reviews
• the qualifications and independence of the clinical peer reviewers
• the confidentiality of the medical records and review materials.

Independent review organization must establish reasonable fees that it will charge for independent reviews and must submit its fee schedule to the commissioner for a determination of reasonableness and for approval. They may not change their fees more than once per year and must submit any proposed fee changes to the commissioner for approval.

The insurance commissioner may:

• Examine, audit or accept an audit of the books and records of an independent review organization with the review organization paying the costs.
• Revoke, suspend or limit the certification of an independent review organization
• Refuse to re-certify an independent review organization.

The insurance commissioner also has the responsibility to write rules for independent reviews. The rules must include at least all of the following:

• The application procedures for certification and re- certification.
• The standards that the commissioner will use for certifying and re-certifying organizations.
• The standards for determining whether an independent review organization is unbiased.
• Procedures and processes that independent review organizations must follow.
• What must be included in required reports to the commissioner.
• Standards for the practices and conduct of independent review organizations.
• Standards addressing conflicts of interest by independent review organizations.

The insurance commissioner is required to submit an annual report to the legislature that specifies
the number of independent reviews requested under this section in the preceding year, the insurers and health benefit plans involved in the independent reviews and the dispositions of the independent reviews.

Conflict of interest standards

An independent review organization may not be affiliated with any of the following:

¨ A health benefit plan.
¨ A national, state or local trade association of health benefit plans.
¨ A national, state or local trade association of health care providers.

An independent review organization may not have a material professional, familial or financial interest with any of the following:

¨ The insurer that is the subject of the independent review.
¨ Any officer, director or management employee of the insurer that is the subject of the independent review.
¨ The health care provider that recommended or provided the health care service or treatment that is the subject of the independent review
¨ The health care provider’s practice group or independent practice association.
¨ The facility at which the health care service or treatment that is the subject of the independent review was or would be provided.
¨ The developer or manufacturer of the principal procedure, equipment, drug or device that is the subject of the independent review.
¨ The insured or his or her authorized representative.

Qualifications of clinical peer reviewers

A clinical peer reviewer who conducts a review on behalf of a certified independent review organization must satisfy all of the following requirements:

• Be a health care provider who is expert in treating the condition that is the subject of the review and who is knowledgeable about the treatment that is the subject of the review through current, actual clinical experience.
• Hold a license that is not limited or restricted.
• Have no history of disciplinary sanctions.

Immunity

A certified independent review organization is immune from any civil or criminal liability that may result because of an independent review determination made under these statutes. An employee, agent or contractor of a certified independent review organization is immune from civil liability and criminal prosecution for any act or omission done in good faith within the scope of his or her powers and duties under these statutes. A health plan that is the subject of an independent review and the insurer that issued the health plan are not be liable for damages attributable to the insurer’s or plan’s actions taken in compliance with any decision rendered by a certified independent review organization.

Statute excerpts

632.83 Internal grievance procedure
632.835(1) Definitions
632.8325(2) Review requirements; who may conduct
632.835(3) Procedure
632.835(3m) Standards for decisions
632.835(4) Certification of independent review organizations
632.83 Internal grievance procedure. 632.83(1) In this section, “health benefit plan” has the meaning given in s. 632.745 (11), except that “health benefit plan” includes the coverage specified in s. 632.745 (11) (b) 10. and includes a policy, certificate or contract under s. 632.745 (11) (b) 9. that provides only limited-scope dental or vision benefits.
632.835(5) Rules; report; adjustments 632.835(6) Conflict of interest standards 635.835(6m) Qualifications of clinical peer reviewers 632.835(7) Immunity 632.835(8) Notice of sufficient independent review organizations 632.835(9) Applicability
632.83(2) Every insurer that issues a health benefit plan shall do all of the following: 632.83(2)(a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (3) for the resolution of insureds’ grievances with the health benefit plan.

632.83(2)(b) Provide insureds with complete and understandable information describing the internal grievance procedure under par. (a).

632.83(2)(c) Submit an annual report to the commissioner describing the internal grievance procedure under par. (a) and summarizing the experience under the procedure for the year.

632.83(3) The internal grievance procedure established under sub. (2) (a) shall include all of the following elements:

632.83(3)(a) The opportunity for an insured to submit a written grievance in any form.

632.83(3)(b) Establishment of a grievance panel for the investigation of each grievance submitted under par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one insured other than the grievant, if an insured is available to serve on the grievance panel.

632.83(3)(c) Prompt investigation of each grievance submitted under par. (a).

632.83(3)(d) Notification to each grievant of the disposition of his or her grievance and of any corrective action taken on the grievance.

632.83(3)(e) Retention of records pertaining to each grievance for at least 3 years after the date of notification under par. (d).

Independent review of adverse and experimental treatment determinations.

632.835(1) Definitions. In this section:

632.835(1)(a) “Adverse determination” means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:

632.835(1)(a)1. An admission to a health care facility, the availability of care, the continued stay or other treatment that is a covered benefit has been reviewed.

632.835(1)(a)2. Based on the information provided, the treatment under subd. 1. does not meet the health benefit plan’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness.

632.835(1)(a)3. Based on the information provided, the insurer that issued the health benefit plan reduced, denied or terminated the treatment under subd. 1. or payment for the treatment under subd. 1.

632.835(1)(a)4. Subject to sub. (5) (c), the amount of the reduction or the cost or expected cost of the denied or terminated treatment or payment exceeds, or will exceed during the course of the treatment, $250.

632.835(1)(b) “Experimental treatment determination” means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:

632.835(1)(b)1. A proposed treatment has been reviewed.

632.835(1)(b)2. Based on the information provided, the treatment under subd. 1. is determined to be experimental under the terms of the health benefit plan.

632.835(1)(b)3. Based on the information provided, the insurer that issued the health benefit plan denied the treatment under subd. 1. or payment for the treatment under subd. 1.

632.835(1)(b)4. Subject to sub. (5) (c), the cost or expected cost of the denied treatment or payment exceeds, or will exceed during the course of the treatment, $250.

632.835(1)(c) “Health benefit plan” has the meaning given in s. 632.745 (11), except that “health benefit plan” includes the coverage specified in s. 632.745 (11) (b) 10.

632.835(1)(d) “Treatment” means a medical service, diagnosis, procedure, therapy, drug or device.

Review requirements; who may conduct.

632.835(2)(a) Every insurer that issues a health benefit plan shall establish an independent review procedure whereby an insured under the health benefit plan, or his or her authorized representative, may request and obtain an independent review of an adverse determination or an experimental treatment determination made with respect to the insured.

632.835(2)(b) Whenever an adverse determination or an experimental treatment determination is made, the insurer involved in the determination shall provide notice to the insured of the insured’s right to obtain the independent review required under this section, how to request the review and the time within which the review must be requested. The notice shall include a current listing of independent review organizations certified under sub. (4). An independent review under this section may be conducted only by an independent review organization certified under sub. (4) and selected by the insured.

632.835(2)(c) Except as provided in par. (d), an insured must exhaust the internal grievance procedure under s. 632.83 before the insured may request an independent review under this section. Except as provided in sub. (9), an insured who uses the internal grievance procedure must request an independent review as provided in sub. (3) (a) within 4 months after the insured receives notice of the disposition of his or her grievance under s. 632.83 (3) (d).

632.835(2)(d) An insured is not required to exhaust the internal grievance procedure under s. 632.83 before requesting an independent review if any of the following apply:

632.835(2)(d)1. The insured and the insurer agree that the matter may proceed directly to independent review under sub. (3).

632.835(2)(d)2. Along with the notice to the insurer of the request for independent review under sub. (3) (a), the insured submits to the independent review organization selected by the insured a request to bypass the internal grievance procedure under s. 632.83 and the independent review organization determines that the health condition of the insured is such that requiring the insured to use the internal grievance procedure before proceeding to independent review would jeopardize the life or health of the insured or the insured’s ability to regain maximum function.

Procedure.

632.835(3)(a) To request an independent review, an insured or his or her authorized representative shall provide timely written notice of the request for independent review, and of the independent review organization selected, to the insurer that made or on whose behalf was made the adverse or experimental treatment determination. The insurer shall immediately notify the commissioner and the independent review organization selected by the insured of the request for independent review. The insured or his or her authorized representative must pay a $25 fee to the independent review organization. If the insured prevails on the review, in whole or in part, the entire amount paid by the insured or his or her authorized representative shall be refunded by the insurer to the insured or his or her authorized representative. For each independent review in which it is involved, an insurer shall pay a fee to the independent review organization.

632.835(3)(b) Within 5 business days after receiving written notice of a request for independent review under par. (a), the insurer shall submit to the independent review organization copies of all of the following:

632.835(3)(b)1. Any information submitted to the insurer by the insured in support of the insured’s position in the internal grievance under s. 632.83.

632.835(3)(b)2. The contract provisions or evidence of coverage of the insured’s health benefit plan.

632.835(3)(b)3. Any other relevant documents or information used by the insurer in the internal grievance determination under s. 632.83.

632.835(3)(c) Within 5 business days after receiving the information under par. (b), the independent review organization shall request any additional information that it requires for the review from the insured or the insurer. Within 5 business days after receiving a request for additional information, the insured or the insurer shall submit the information or an explanation of why the information is not being submitted.

632.835(3)(d) An independent review under this section may not include appearances by the insured or his or her authorized representative, any person representing the health benefit plan or any witness on behalf of either the insured or the insurer.

632.835(3)(e) In addition to the information under pars. (b) and (c), the independent review organization may accept for consideration any typed or printed, verifiable medical or scientific evidence that the independent review organization determines is relevant, regardless of whether the evidence has been submitted for consideration at any time previously. The insurer and the insured shall submit to the other party to the independent review any information submitted to the independent review organization under this paragraph and pars. (b) and (c). If, on the basis of any additional information, the insurer reconsiders the insured’s grievance and determines that the treatment that was the subject of the grievance should be covered, the independent review is terminated.

632.835(3)(f) If the independent review is not terminated under par. (e), the independent review organization shall, within 30 business days after the expiration of all time limits that apply in the matter, make a decision on the basis of the documents and information submitted under this subsection. The decision shall be in writing, signed on behalf of the independent review organization and served by personal delivery or by mailing a copy to the insured or his or her authorized representative and to the insurer. A decision of an independent review organization is binding on the insured and the insurer.

632.835(3)(g) If the independent review organization determines that the health condition of the insured is such that following the procedure outlined in pars. (b) to (f) would jeopardize the life or health of the insured or the insured’s ability to regain maximum function, the procedure outlined in pars. (b) to (f) shall be followed with the following differences:

632.835(3)(g)1. The insurer shall submit the information under par. (b) within one day after receiving the notice of the request for independent review under par. (a).

632.835(3)(g)2. The independent review organization shall request any additional information under par. (c) within 2 business days after receiving the information under par. (b).

632.835(3)(g)3. The insured or insurer shall, within 2 days after receiving a request under par. (c), submit any information requested or an explanation of why the information is not being submitted.

632.835(3)(g)4. The independent review organization shall make its decision under par. (f) within 72 hours after the expiration of the time limits under this paragraph that apply in the matter.

Standards for decisions.

632.835(3m)(a) A decision of an independent review organization regarding an adverse determination must be consistent with the terms of the health benefit plan under which the adverse determination was made.

632.835(3m)(b) A decision of an independent review organization regarding an experimental treatment determination is limited to a determination of whether the proposed treatment is experimental. The independent review organization shall determine that the treatment is not experimental and find in favor of the insured only if the independent review organization

finds all of the following:

632.835(3m)(b)1. The treatment has been approved by the federal food and drug administration, if the treatment is subject to the approval of the federal food and drug administration.

632.835(3m)(b)2. Medically and scientifically accepted evidence clearly demonstrates that the treatment meets all of the following criteria:

632.835(3m)(b)2.a. The treatment is proven safe.

632.835(3m)(b)2.b. The treatment can be expected to produce greater benefits than the standard treatment without posing a greater adverse risk to the insured.

632.835(3m)(b)2.c. The treatment meets the coverage terms of the health benefit plan and is not specifically excluded under the terms of the health benefit plan.

Certification of independent review organizations.

632.835(4)(a) The commissioner shall certify independent review organizations. An independent review organization must demonstrate to the satisfaction of the commissioner that it is unbiased, as defined by the commissioner by rule. An organization certified under this paragraph must be recertified on a biennial basis to continue to provide independent review services under this section.

632.835(4)(ag) An independent review organization shall have in operation a quality assurance mechanism to ensure the timeliness and quality of the independent reviews, the qualifications and independence of the clinical peer reviewers and the confidentiality of the medical records and review materials.

632.835(4)(ap) An independent review organization shall establish reasonable fees that it will charge for independent reviews and shall submit its fee schedule to the commissioner for a determination of reasonableness and for approval. An independent review organization may not change any fees approved by the commissioner more than once per year and shall submit any proposed fee changes to the commissioner for approval.

632.835(4)(b) An organization applying for certification or recertification as an independent review organization shall pay the applicable fee under s. 601.31 (1) (Lp) or (Lr). Every organization certified or recertified as an independent review organization shall file a report with the commissioner in accordance with rules promulgated under sub. (5) (a) 4.

632.835(4)(c) The commissioner may examine, audit or accept an audit of the books and records of an independent review organization as provided for examination of licensees and permittees under s. 601.43 (1), (3), (4) and (5), to be conducted as provided in s. 601.44, and with costs to be paid as provided in s. 601.45.

632.835(4)(d) The commissioner may revoke, suspend or limit in whole or in part the certification of an independent review organization, or may refuse to recertify an independent review organization, if the commissioner finds that the independent review organization is unqualified or has violated an insurance statute or rule or a valid order of the commissioner under s. 601.41 (4), or if the independent review organization’s methods or practices in the conduct of its business endanger, or its financial resources are inadequate to safeguard, the legitimate interests of consumers and the public. The commissioner may summarily suspend an independent review organization’s certification under s. 227.51 (3).

632.835(4)(e) The commissioner shall keep an up-to-date listing of certified independent review organizations and shall provide a copy of the listing to all of the following:

632.835(4)(e)1. Every insurer that is subject to this section, at least quarterly.

632.835(4)(e)2. Any person who requests a copy of the listing.

Rules; report; adjustments.

632.835(5)(a) The commissioner shall promulgate rules for the independent review required under this section. The rules shall include at least all of the following:

632.835(5)(a)1. The application procedures for certification and recertification as an independent review organization.

632.835(5)(a)2. The standards that the commissioner will use for certifying and recertifying organizations as independent review organizations, including standards for determining whether an independent review organization is unbiased.

632.835(5)(a)3. Procedures and processes, in addition to those in sub. (3), that independent review organizations must follow.

632.835(5)(a)4.What must be included in the report required under sub. (4) and the frequency with which the report must be filed with the commissioner.

632.835(5)(a)5. Standards for the practices and conduct of independent review organizations.

632.835(5)(a)6. Standards, in addition to those in sub. (6), addressing conflicts of interest by independent review organizations.

632.835(5)(b) The commissioner shall annually submit a report to the legislature under s. 13.172 (2) that specifies the number of independent reviews requested under this section in the preceding year, the insurers and health benefit plans involved in the independent reviews and the dispositions of the independent reviews.

632.835(5)(c) To reflect changes in the consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor, the commissioner shall at least annually adjust the amounts specified in sub. (1) (a) 4. and (b) 4.

Conflict of interest standards.

632.835(6)(a) An independent review organization may not be affiliated with any of the following:

632.835(6)(a)1. A health benefit plan.

632.835(6)(a)2. A national, state or local trade association of health benefit plans, or an affiliate of any such association.

632.835(6)(a)3. A national, state or local trade association of health care providers, or an affiliate of any such association.

632.835(6)(b) An independent review organization appointed to conduct an independent review and a clinical peer reviewer assigned by an independent review organization to conduct an independent review may not have a material professional, familial or financial interest with any of the following:

632.835(6)(b)1. The insurer that issued the health benefit plan that is the subject of the independent review.

632.835(6)(b)2. Any officer, director or management employee of the insurer that issued the health benefit plan that is the subject of the independent review.

632.835(6)(b)3. The health care provider that recommended or provided the health care service or treatment that is the subject of the independent review, or the health care provider’s medical group or independent practice association.

632.835(6)(b)4. The facility at which the health care service or treatment that is the subject of the independent review was or would be provided.

632.835(6)(b)5. The developer or manufacturer of the principal procedure, equipment, drug or device that is the subject of the independent review.

632.835(6)(b)6. The insured or his or her authorized representative.

632.835(6m) Qualifications of clinical peer reviewers. A clinical peer reviewer who conducts a review on behalf of a certified independent review organization must satisfy all of the following requirements:

632.835(6m)(a) Be a health care provider who is expert in treating the medical condition that is the subject of the review and who is knowledgeable about the treatment that is the subject of the review through current, actual clinical experience.

632.835(6m)(b) Hold a credential, as defined in s. 440.01 (2) (a), that is not limited or restricted; or hold a license, certificate, registration or permit that authorizes or qualifies the health care provider to perform acts substantially the same as those acts authorized by a credential, as defined in s. 440.01 (2) (a), that was issued by a governmental authority in a jurisdiction outside this state and that is not limited or restricted.

632.835(6m)(c) If a physician, hold a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the review.

632.835(6m)(d) Have no history of disciplinary sanctions, including loss of staff privileges but excluding temporary suspension of staff privileges due to incomplete records, taken or pending by the medical examining board or another regulatory body or by any hospital or government.

Immunity.

632.835(7)(a) A certified independent review organization is immune from any civil or criminal liability that may result because of an independent review determination made under this section. An employee, agent or contractor of a certified independent review organization is immune from civil liability and criminal prosecution for any act or omission done in good faith within the scope of his or her powers and duties under this section.

632.835(7)(b) A health benefit plan that is the subject of an independent review and the insurer that issued the health benefit plan shall not be liable to any person for damages attributable to the insurer’s or plan’s actions taken in compliance with any decision rendered by a certified independent review organization.

632.835(8) Notice of sufficient independent review organizations. The commissioner shall make a determination that at least one independent review organization has been certified under sub. (4) that is able to effectively provide the independent reviews required under this section and shall publish a notice in the Wisconsin Administrative Register that states a date that is 2 months after the commissioner makes that determination. The date stated in the notice shall be the date on which the independent review procedure under this section begins operating.

632.835(9) Applicability. The independent review required under this section shall be available to an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after December 1, 2000. Notwithstanding sub. (2) (c), an insured who receives notice of the disposition of his or her grievance under s. 632.83 (3) (d) on or after December 1, 2000, but before the date stated in the notice published by the commissioner in the Wisconsin Administrative Register under sub. (8) .... [revisor inserts date], must request an independent review no later than 4 months after the date stated in the notice published by the commissioner in the Wisconsin Administrative Register under sub. (8) .... [revisor inserts date].

Health Benefit Plan Grievances and Independent Review Organizations

SUBCHAPTER I – DEFINITIONS

Ins 18.01 DEFINITIONS. In this chapter:

(1) “Commissioner” means the “commissioner of insurance” of this state or the commissioner’s designee.

(2) “Complaint” means any expression of dissatisfaction expressed to the insurer by the insured, or an insured’s authorized representative, about an insurer or its providers with whom the insurer has a direct or indirect contract.

(3) “Expedited grievance” means a grievance where any of the following applies:

(a) The duration of the standard resolution process will result in serious jeopardy to the life or health of the insured or the ability of the insured to regain maximum function.
(b) In the opinion of a physician with knowledge of the insured’s medical condition, the insured is subject to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance.
(c) A physician with knowledge of the insured’s medical condition determines that the grievance shall be treated as an expedited grievance.

(4) “Grievance” means any dissatisfaction with the provision of services or claims practices of an insurer offering a health benefit plan or administration of a health benefit plan by the insurer that is expressed in writing to the insurer by, or on behalf of, an insured.

(5) “Independent review organizations” means an organization certified under s. 632.835 (4), Stats.

(6) “Independent review” means a review conducted by a certified independent review organization.

(7) “Insured” has the meaning provided in s. 600.03 (23), Stats.

(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.

(9) “Office” means the “office of the commissioner of insurance.”

SUBCHAPTER II – GRIEVANCE PROCEDURES

Ins 18.02 DEFINITIONS. In addition to the definitions in s. 632.83, Stats., in this subchapter: 4

(1) “Health benefit plan” has the meaning provided in s. 632.83, Stats., and includes Medicare supplement and replacement plans as defined in ss. 600.03 (28p) and (28r), Stats., and ss.

Ins 3.39 (3) (f) and (g). Health benefit plan includes Medicare Cost and Select plans but does not include Medicare + Choice plans.

Ins 18.03 GRIEVANCES.

(1) DEFINITION AND EXPLANATION OF THE GRIEVANCE PROCEDURE.

(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).
(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.
(c) In accordance with s. 632.83 (2) (a), Stats., an insurer that offers a health benefit plan shall investigate each grievance.

(2) NOTIFICATION OF RIGHT TO APPEAL DETERMINATIONS.

(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.
(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.
(c) 1. An insurer offering a health benefit plan that is a managed care plan as defined in s. 609.01 (3c), Stats., other than a preferred provider plan as defined in s. 609.01 (4), Stats., shall do all of the following:
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.
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.
c. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.
d. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.

(c) 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:
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.
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.
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.
d. Process and respond to a complaint or grievance described under subd. 2. c.
e. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.
f. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.

(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.

(3) GRIEVANCE PROCEDURE. The grievance procedure utilized by an insurer offering a health
benefit plan shall include all of the following:

(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.
(b) A written notification to the insured of the time and place of the grievance meeting at least 7 calendar days before the meeting.
(c) Reasonable accommodations to allow the insured, or the insured’s authorized representative, to participate in the meeting.
(d) The grievance panel shall comply with the requirements of s. 632.83 (3) (b), Stats., and shall not include the person who ultimately made the initial determination. If the panel consists of at least three persons, the panel may then include no more than one subordinate of the person who ultimately made the initial determination. The panel may, however, consult with the ultimate initial decision-maker.
(e) The insured member of the panel shall not be an employee of the plan, to the extent possible.
(f) Consultation with a licensed health care provider with expertise in the field relating to the grievance, if appropriate.
(g) The panel’s written decision to the insured as described in s. 632.83 (3) (d), Stats., shall be signed by one voting member of the panel and include a written description of position titles of panel members involved in making the decision.

(4) RECEIPT OF GRIEVANCE ACKNOWLEDGMENT. An insurer offering a health benefit plan shall, within 5 business days of receipt of a grievance, deliver or deposit in the mail a written acknowledgment to the insured or the insured’s authorized representative confirming receipt of the grievance.

(5) AUTHORIZATION FOR RELEASE OF INFORMATION.

(a) An insurer offering a health benefit plan may require a written expression of authorization for representation from a person acting as the insured’s authorized representative unless any of the following applies:
1. The person is authorized by law to act on behalf of the insured.
2. The insured is unable to give consent and the person is a spouse, family member or the treating provider.
3. The grievance is an expedited grievance and the person represents that the insured has verbally given authorization to represent the insured.

(b) An insurer offering a health benefit plan shall process a grievance without requiring written authorization unless the insurer, in its acknowledgement to the person under sub. (4), clearly and prominently does all of the following:
1. Notifies the person that, unless an exception under par. (a) applies, the grievance will not be processed until the insurer receives a written authorization.
2. Requests written authorization from the person.
3. Provides the person with a form the insured may use to give written authorization. An insured may, but is not required to, use the insurer’s form to give written authorization.

(c) An insurer offering a health benefit plan shall accept under par. (a) any written expression of authorization without requiring specific form, language or format.

(d) An insurer offering a health benefit plan shall include in its acknowledgement of receipt of a grievance filed by an authorized representative a clear and prominent notice that health care information or medical records may be disclosed only if permitted by law. The acknowledgement shall state that unless otherwise permitted under applicable law, including the Health Insurance Portability and Accountability Act of 1996, U.S. PL 104-191, ss. 51.30, 146.82 to 146.86, and 610.70, Stats., and ch. Ins 25, informed consent is required and the acknowledgement shall include an informed consent form for that purpose. An insurer offering a health benefit plan may withhold health care information or medical records from an authorized representative, including information contained in its resolution of the grievance, but only if disclosure is prohibited by law. An insurer offering a health benefit plan shall process a grievance submitted by an authorized representative regardless of whether health care information or medical records may be disclosed to the authorized representative under applicable law.

(6) RESOLUTION OF A GRIEVANCE.

An insurer offering a health benefit plan shall resolve a grievance:

(a) For a grievance that is a review of a benefit determination that is subject to 29 CFR 2560.503-1, within the time provided under 29 CFR 2560-503-1 (i).
(b) For any grievance not subject to par. (a), within 30 calendar days of receiving the grievance. If the insurer offering a health benefit plan is unable to resolve the grievance within 30 calendar days, the time period may be extended an additional 30 calendar days, if the insurer provides a written notification to the insured and the insured’s authorized representative, if applicable, of all of the following:
1. That the insurer has not resolved the grievance.
2. When resolution of the grievance may be expected.
3. The reason additional time is needed.

(7) COMMISSIONER ANNUAL REPORT. The commissioner shall by June 1 of each year prepare a report that summarizes grievance experience reports received by the commissioner from insurers offering health benefit plans. The report shall also summarize OCI complaints involving the insurer offering health benefit plans that were received by the office during the previous calendar year.

Ins 18.04 RIGHT OF THE COMMISSIONER TO REQUEST OCI COMPLAINTS BE HANDLED AS GRIEVANCES.

The commissioner may require an insurer offering a health benefit plan to treat and process an OCI complaint as a grievance as appropriate, if the commissioner provides a written description of the complaint to the insurer. The insurer shall process the OCI complaint as a grievance in compliance with s. 18.03.

Ins 18.05 EXPEDITED GRIEVANCE PROCEDURE.

Sections 18.03 (2) to (4) and (6) do not apply to expedited grievances. For these situations, an insurer offering a health benefit plan shall develop a separate expedited grievance procedure. An expedited grievance shall be resolved as expeditiously as the insured’s health condition requires but not more than 72 hours after receipt of the grievance.

Ins 18.06 REPORTING REQUIREMENTS. An insurer offering a health benefit plan shall comply with all of the following requirements:

(1) Each record of each complaint and grievance submitted to the insurer shall be kept and retained for a period of at least 3 years. These records shall be maintained at the insurer’s home or principal office and shall be available for review during examinations by or on request of the commissioner or office.

(2) Submit a grievance experience report required by s. 632.83 (2) (c), Stats., to the commissioner by March 1 of each year. The report shall provide information on all grievances received during the previous calendar year. The report shall be in a form prescribed by the commissioner and, at a minimum, shall classify grievances into the following categories:
(a) Plan administration including plan marketing, policyholder service, billing, underwriting and similar administrative functions.
(b) Benefit services including denial of a benefit, denial of experimental treatment, quality of care, refusal to refer insureds or to provide requested services.

SUBCHAPTER III – INDEPENDENT REVIEW PROCEDURES

Ins 18.10 DEFINITIONS. In addition to the definitions in s. 632.835 (1), Stats., in this subchapter:

(1) “Adverse determination” has the meaning as defined in s. 632.835 (1) (a), Stats. This includes the denial of a request for a referral for out-of-network services when the insured requests health care services from a provider that does not participate in the insurer’s provider network because the clinical expertise of the provider may be medically necessary for treatment of the insured’s medical condition and that expertise is not available in the insurer’s provider network.

(2) “Experimental treatment determination” means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:
(a) A proposed treatment has been reviewed.
(b) Based on the information provided, the treatment under par. (a) is determined to be experimental under the terms of the health benefit plan.
(c) Based on the information provided, the insurer that issued the health benefit plan denied the treatment under par. (a) or payment for the treatment under par. (a).
(d) Subject to s. 632.835 (5) (c), Stats., the cost or expected cost of the denied treatment or payment exceeds, or will exceed during the course of the treatment, $250.

(3) “Health benefit plan” has the meaning provided in s. 632.835 (1) (c), Stats., and includes Medicare supplement and replacement plans as defined in ss. 600.03 (28p) and (28r), Stats., and ss.3.39 (3) (f) and (g). Health benefit plan including Medicare Cost and Select plans but does not include Medicare + Choice plans.

(4) “Medical or scientific evidence” means information from any of the following sources:

(a) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.
(b) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health’s Library of Medicine for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline and MEDLARS database Health Services Technology Assessment Research (HSTAR).
(c) Medical journals recognized by the Secretary of Health and Human Services under 42 USC1320c et. seq. of the federal Social Security Act.
(d) Any of the following standard reference compendia:
1. The American Hospital Formulary Service – Drug Information.
2. The American Medical Association of Drug Evaluation.
3. The American Dental Association Accepted Dental Therapeutics.
4. The United States Pharmacopoeia – Drug Information.
(e) Findings, studies or research conducted by, or under the auspices of, federal governmental agencies and nationally recognized federal research institutes, including:
1. The federal Agency for Healthcare Research and Quality.
2. The National Institutes of Health.
3. The National Cancer Institute.
4. The National Academy of Sciences.
5. The Health Care Financing Administration.
6. Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services.
7. Any other medical or scientific evidence that is comparable to the sources listed in this paragraph.

(5) “Unbiased” means an independent review organization that complies with all of the following:

(a) Section 632.835 (6), Stats.
(b) The independent review organization does not provide incentives of any kind, including financial incentives, to providers or consumers as inducements for selection as the independent review organization.
(c) The independent review organization does not directly or indirectly receive any compensation, in any form, related to a review, other than the compensation permitted under this subchapter and s. 632.835, Stats.
(d) The independent review organization does not promote, to providers, consumers or insurers any of the following:
1. A pattern of favorable results or a pattern of favorable results on a particular treatment or subject.
2. An association with a class of providers, consumers or insurers.
3. A bias favorable to a class of providers, consumers or insurers.
(e) The independent review organization does not have a pattern of decisions that are unsupported by substantial evidence.

Ins 18.11 INDEPENDENT REVIEW.

(1) INDEPENDENT REVIEW PROCEDURES. Each insurer offering a health benefit plan shall establish procedures to ensure compliance with this section and s. 632.835, Stats.

(2) NOTIFICATION OF RIGHT TO INDEPENDENT REVIEW. In addition to the requirements of s. 632.835 (2) (b), Stats., and s. 18.03, each time an insurer offering a health benefit plan makes an adverse determination or an experimental treatment determination the insurer shall provide all of the following in the notice to insureds:
(a) A notice to an insured of the right to request an independent review. The notice shall comply with s. 632.835 (2) (b), Stats., and be accompanied by the informational brochure developed by the office, or in a form substantially similar, describing the independent review process. The notice shall be sent when the insurer offering a health benefit plan makes an adverse determination or experimental treatment determination. In addition, the notice shall contain all of the following information:
1. In accordance with s. 632.835 (9), Stats., for adverse determinations or experimental treatment determinations occurring on or after December 1, 2000, but prior to the date stated in the notice published by the commissioner in the Wisconsin Administrative Register under s. 632.835 (8), 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), Stats..
2. For adverse determinations or experimental treatment determinations occurring subsequent to the date stated in the notice published by the commissioner in the Wisconsin Administrative Register under s. 632.835 (8), Stats., the notice to an insured shall, in accordance with s. 632.835 (2) (c), Stats., state that the insured, or the insured’s authorized representative, must request independent review within 4 months from the date of the adverse determination or experimental treatment determination by the insurer or from the date of receipt of notice of the grievance panel decision, whichever is later.
3. The notice shall state that the insured, or the insured’s authorized representative, shall select the independent review organization from the list of certified independent review organizations, accompanying the notice, as compiled by the commissioner and available from the insurer. 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.
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, contain the name of the selected independent review organization and be accompanied with the $25 fee payable to the 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. The notice shall state that if the insured or insured’s authorized representative prevails in the review, either in whole or in part, the $25 fee paid to the independent review organization will be refunded to the insured by the insurer.
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 is binding upon the insurer and insured.
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:
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.
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.

(3) INDEPENDENT REVIEW TIMEFRAMES. In addition to the requirements set forth in s. 632.835 (3), Stats., the following procedures shall be followed:

(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.
(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.
(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.
(d) Subdivisions (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 18.12 INDEPENDENT REVIEW ORGANIZATION PROCEDURES.

(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:
(a) A regulatory compliance program that does all of the following:
1. Tracks applicable independent review laws and regulations.
2. Ensures the organization’s compliance with applicable laws.
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.
(b) A procedure to determine, upon receipt of the referral for review, all of the following:
1. Whether a conflict of interest exists. If a conflict exists, the independent review organization shall provide an written notification to the insurer, the commissioner and the insured within 3 business days stating that a conflict exists and that a different independent review organization will need to be selected by the insured.
2. The type of case for which review is sought. The independent review organization shall determine if the case relates to an adverse determination, experimental treatment determination or an administrative issue. If the independent review organization determines that the review is not related to an adverse determination or experimental treatment determination, the independent review organization shall provide written notification to the commissioner, the insured and the insurer of its determination within 2 business days.
3. The specific question or issue that is to be resolved by the independent review process.
4. Whether the cost of treatment or course of treatment is at least $250. In determining the cost of treatment or cost of the course of treatment, the independent review organization shall calculate the amount as the actual cost charged the insured if the treatment is denied, without deduction for cost sharing or contractual agreements with providers.
5. Whether the case merits standard review or expedited review.
(c) Criteria for the number and qualification of reviewers. The criteria must meet the requirements of sub. (4).
(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.
(e) Procedures for consideration of pertinent information for cases referred to independent review organizations regarding an adverse determination, including all of the following:
1. The insured’s medical records.
2. The attending provider’s recommendation.
3. The terms of coverage under the insured’s health benefit plan.
4. Information accumulated regarding the case prior to its referral to independent review, including the rationale for prior review determinations.
5. Information submitted to the independent review organization by the referring entity, insured or attending provider.
6. Clinical review criteria developed and used by the insurer.
7. Medical or scientific evidence, as appropriate.
(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.
(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.
(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:
1. The question or issue that was referred for review.
2. A description of the qualifications of the reviewer or reviewers.
3. A clinical rationale or explanation for the independent review organization’s determination, including supporting evidence and a clear statement of the decision.
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.
(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.
(j) Procedures to ensure that the decision of the independent review organization is consistent with s. 632.835 (3m), Stats.

(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:
(a) That the independent reviews are conducted within the specified time frames and that required notices are provided in a timely manner.
(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.
(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.
(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.
(e) That any person employed by, or under contract with, the independent review organization adheres to the requirements of this section.
(f) That management reports are adequate to track and monitor matters described in pars. (a) to (e).

(3) ACCESSIBILITY.

(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.
(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).

(4) REVIEWER QUALIFICATIONS. In addition to the requirements of s. 632.835 (6m), Stats., the independent review organization shall require all clinical peer reviewers assigned to conduct independent 18 reviews to be physicians or other appropriate health care providers whose qualifications are verified at least every 2 years.

(5) CONFLICT OF INTEREST. In addition to the requirements in s. 632.835 (6), Stats., all clinical peer reviewers shall, at least quarterly, provide to the independent review organization a list of potential conflicts of interest.

(6) DIRECTOR.
(a) Except as provided in par. (b), an independent review organization shall employ or contract with a medical director with professional post-residency experience in direct patient care who holds a current license to practice medicine and who has a clinical specialty appropriate to the type of reviews conducted by the independent review organization.
(b) An independent review organization that limits its reviews to matters related to a particular type of health care may employ or contract with a clinical director. The clinical director shall be trained and hold a current license in a medical or health care specialty appropriate to the full scope of the organization’s review.
(c) The independent review organization shall require the medical director or clinical director to oversee the medical or health care aspects of quality assurance and credentialing programs.

(7) DELEGATED FUNCTIONS. The independent review organization may delegate or subcontract review functions. Nevertheless, the independent review organization is responsible for the delegated or subcontracted functions, including any violation of law, policy or procedure. In addition, an independent review organization that delegates or subcontracts independent review functions shall provide documentation and verification of all of the following:
(a) Written contracts with the subcontractor that delineates with specificity all duties and responsibilities.
(b) A review by the independent review organization, on at least an annual basis, of the subcontractor’s policies, procedures, and quality assurance program, if relevant to the subcontracted functions.
(c) A review by the independent review organization, on at least an annual basis, of the subcontractor’s performance and compliance, monitored by the independent review organization, with stated policies, procedures, quality assurance programs and applicable laws.
(d) A review by the independent review organization, on at least an annual basis, of the effectiveness of communication and coordination of processes between the independent review organization and the subcontractor.

(8) UNBIASED. An independent review organization shall be unbiased. An independent review organization shall establish and maintain procedures to ensure that it is unbiased.

Ins 18.14 APPROVAL OF INDEPENDENT REVIEW ORGANIZATIONS.

(1) In addition to meeting the requirements established s. 632.835 (4) (a), Stats., any independent review organization seeking approval to conduct independent reviews shall submit an application for approval on a form prescribed by the commissioner and include with the form all documentation and information necessary for the commissioner to determine if the independent review organization is unbiased and satisfies s. Ins 18.12.

(2) The independent review organization shall submit informational materials to the commissioner as part of the application. Materials will be maintained in the office for public review.

(3) The independent review organization shall submit the application fee in accordance with s. 601.31 (1) (Lp), Stats., at the time of the application to an identified lock box address.

Ins 18.16 INDEPENDENT REVIEW ORGANIZATION REPORTING REQUIREMENTS.

(1) An independent review organization shall maintain records on all independent review activity during each calendar year and submit a report to the commissioner, on a form prescribed by the commissioner, by March 1 of each year for the prior calendar year’s experience. Records shall be maintained so that, at a minimum, they satisfy the reporting requirements to the commissioner and shall be retained for at least 3 years.

(2) The annual report shall include all of the following information on an aggregate basis, by insurer and by insurer and insurance product name:
(a) The total number of requests for independent review received.
(b) The total number of requests for independent review declined and the reason for the declination, including whether the request was a qualified request or within the scope of the health benefit plan policy.
(c) The total number of requests for expedited independent review that the independent review organization declined to handle in an expedited timeframe, including whether the request was a qualified request or within the scope of the health benefit plan policy.
(d) The number of independent reviews that were done in an expedited manner and the results of those reviews.
(e) The number of requests for independent review resolved and, of those resolved, the number resolved upholding the adverse determination or experimental treatment determination by the insurer and the number resolved reversing the adverse determination or experimental treatment determination by the insurer.
(f) The average length of time for resolution.
(g) A detailed summary of cases including a synopsis of facts, rationale for decision and key evidence relied upon to reach the reviewer’s decision. The summary shall also include the types of cases or coverage for which an independent review was sought.
(h) The cost of reviews both in the aggregate and on a case by case basis.
(i) The number of independent reviews that were terminated as the result of reconsideration by the insurer offering a health benefit plan of its adverse determination or experimental treatment determination after the receipt of additional information from the insured, the insured’s authorized representative, or other appropriate sources.
(j) Any other information the commissioner requests.

INS 18.18 INDEPENDENT REVIEW ORGANIZATION FEES.

(1) A certified independent review organization shall submit its fee schedule in accordance with s. 632.835 (4) (ap), Stats., to the commissioner for review and approval.

(2) Fee schedules shall be based on prevailing rates in the industry demonstrated by supporting credible documentation including actual costs for conducting the reviews. Fee schedules shall 21 be on a per case basis according to categories established by the commissioner. The fee schedule shall include a category for the fee payable for a review that is terminated because the insurer voluntarily reverses its decision because of information first received by the insurer after the review is requested.

(3) An insurer offering a health benefit plan shall pay the fee submitted by the independent review organization within 30 days of receipt of a written invoice or billing record from the independent review organization.

(4) The independent review organization may only charge the fees in accordance with the fee schedule that is approved by the commissioner.

(5) An independent review organization is required to charge the insured a $25 filing fee in accordance with s. 632.835 (3) (a), Stats., that shall be refunded by the insurer if the insured prevails in the review. The $25 filing fee shall be considered a part of the overall cost for a qualified review. The independent review organization may not bill the insured for the cost of the review.

(6) If an independent review organization determines the matter is not within its authority to review, it may charge no more than the filing fee for that determination.