SB246,7,524 (e) The independent review organization shall provide to the limited service
25health organization, preferred provider plan or managed care plan any additional

1information received from the enrollee under pars. (c) and (d). If, on the basis of the
2additional information, the limited service health organization, preferred provider
3plan or managed care plan reconsiders the enrollee's grievance and determines that
4the treatment that was the subject of the grievance should be covered, the
5independent review is terminated.
SB246,7,136 (f) If the independent review is not terminated under par. (e), the expert
7reviewers on behalf of the independent review organization shall, within 15 business
8days after the expiration of all time limits that apply in the matter, make a
9determination on the basis of the documents and information submitted under this
10subsection. The independent review organization shall send by 1st class mail to the
11commissioner, the enrollee and the limited service health organization, preferred
12provider plan or managed care plan a copy of the determination, which shall be in
13writing and state the basis for the decision.
SB246,7,1814 (g) If, in the judgment of the enrollee's treating health care provider, the health
15condition of the enrollee is such that following the procedure outlined in pars. (a) to
16(f) would jeopardize the life or health of the enrollee or the enrollee's ability to regain
17maximum function, the procedure outlined in pars. (a) to (f) shall be followed with
18the following differences:
SB246,7,2119 1. The limited service health organization, preferred provider plan or managed
20care plan shall submit the information under par. (a) within one day after receiving
21the notification under sub. (3) (b).
SB246,7,2422 2. The independent review organization shall request any additional
23information under par. (d) within 2 business days after receiving the information
24under par. (a).
SB246,8,4
13. The enrollee or limited service health organization, preferred provider plan
2or managed care plan shall, within 2 days after receiving a request under par. (d),
3submit any information requested or an explanation of why the information is not
4being submitted.
SB246,8,75 4. The expert reviewers shall make their determination under par. (f) within
672 hours after the expiration of the time limits under this paragraph that apply in
7the matter.
SB246,8,108 (h) Any time limits specified in this subsection may be extended by mutual
9agreement between the enrollee, or his or her authorized representative, and the
10limited service health organization, preferred provider plan or managed care plan.
SB246,8,1211 (i) Any information required or authorized to be submitted under this
12subsection may be submitted by facsimile or other electronic transmission.
SB246,8,14 13(5) Standards for review. In making the determination under sub. (4) (f), all
14of the following apply:
SB246,8,1915 (a) If coverage of the treatment that is the subject of the review was denied on
16the basis that the treatment was not medically necessary or appropriate, the expert
17reviewers shall find that the treatment was medically necessary and appropriate if,
18in light of conditions at the time the treatment was proposed, the treatment satisfied
19all of the following:
SB246,8,2120 1. Was appropriate and consistent with the diagnosis and not providing it could
21adversely affect or fail to improve the enrollee's condition.
SB246,8,2322 2. Was compatible with the standards of acceptable medical practice in the
23United States.
SB246,8,2524 3. Was provided, or was to be provided, in a safe and appropriate setting, given
25the nature of the diagnosis and the severity of the symptoms.
SB246,9,2
14. Was not provided, or was not to be provided, solely for the convenience of the
2enrollee, the health care provider or the hospital.
SB246,9,43 5. Was not primarily custodial care, unless custodial care is a covered benefit
4under the enrollee's coverage.
SB246,9,75 (b) If coverage of the treatment that is the subject of the review was denied on
6the basis that the treatment was experimental, the expert reviewers shall find in
7favor of the enrollee if all of the following apply:
SB246,9,98 1. The treatment has been approved by the federal food and drug
9administration.
SB246,9,1310 2. Medically and scientifically accepted evidence demonstrates that the
11expected benefits of the proposed treatment would be greater than the benefits of any
12available standard treatment and that the adverse risks of the proposed treatment
13are not substantially higher than those of standard treatments.
SB246,9,1614 (c) The expert reviewers shall apply prudent professional practices and shall
15ensure that medically and scientifically accepted evidence supports the
16determination.
SB246,9,20 17(6) Effect of determination. (a) A determination under sub. (4) (f) in favor
18of the enrollee is final and binding on the limited service health organization,
19preferred provider plan or managed care plan, which shall promptly comply with the
20determination.
SB246,9,2521 (b) A determination under sub. (4) (f) in favor of the limited service health
22organization, preferred provider plan or managed care plan creates a rebuttable
23presumption in any subsequent action that the original coverage determination of
24the limited service health organization, preferred provider plan or managed care
25plan was appropriate.
SB246,10,6
1(c) An independent review organization is immune from any civil or criminal
2liability that may result because of an independent review determination made
3under this section. An employe, agent or contractor of an independent review
4organization is immune from civil liability and criminal prosecution for any act or
5omission done in good faith within the scope of his or her powers and duties under
6this section.
SB246,10,9 7(7) Independent review organizations; certification. (a) The commissioner
8shall certify and recertify independent review organizations that may conduct
9independent reviews under this section.
SB246,10,1110 (b) An independent review organization shall submit to the commissioner in
11its application for certification the following information:
SB246,10,1312 1. The names of all owners of more than 5% of any stock or options, if a publicly
13held organization.
SB246,10,1414 2. The names of all holders of bonds or notes in excess of $100,000, if any.
SB246,10,1715 3. The names and types of business of all corporations and organizations that
16the independent review organization controls or is affiliated with and the nature and
17extent of any ownership or control.
SB246,10,2118 4. The names of all directors, officers and executives of the independent review
19organization and the nature of any relationship that a director, officer or executive
20has, if any, with a provider group or a health care insurer, including a limited service
21health organization, preferred provider plan or managed care plan.
SB246,10,2322 (c) Within 30 days of any change in the information submitted under par. (b),
23the independent review organization shall notify the commissioner of the change.
SB246,11,3
1(d) An independent review organization may not be a subsidiary of, or owned
2or controlled by, a health care plan, a trade association of health care plans or a
3professional association of health care providers.
SB246,11,54 (e) An expert reviewer assigned by an independent review organization to
5conduct a review must satisfy all of the following requirements:
SB246,11,86 1. Be a health care provider who is expert in treating the medical condition that
7is the subject of the review and who is knowledgeable about the treatment that is the
8subject of the review through actual clinical experience.
SB246,11,149 2. Hold a credential, as defined in s. 440.01 (2) (a), that is not limited or
10restricted; or hold a license, certificate, registration or permit that authorizes or
11qualifies the health care provider to perform acts that are substantially the same as
12those acts authorized by a credential, as defined in s. 440.01 (2) (a), that was issued
13by a governmental authority in a jurisdiction outside this state and that is not
14limited or restricted.
SB246,11,1615 3. If a physician, hold a current certification by a recognized American medical
16specialty board in the area or areas appropriate to the subject of the review.
SB246,11,1917 4. Have no history of disciplinary sanctions, including loss of staff privileges,
18taken or pending by the medical examining board or another regulatory body or by
19any hospital or government.
SB246,11,2220 (f) An independent review organization or an expert reviewer of the
21organization may not have any material professional, familial or financial conflict
22of interest with any of the following:
SB246,11,2523 1. A limited service health organization, preferred provider plan or managed
24care plan that is involved in a review being conducted by the organization or
25reviewer.
SB246,12,3
12. An officer, director or management employe of a limited service health
2organization, preferred provider plan or managed care plan that is involved in a
3review being conducted by the organization or reviewer.
SB246,12,64 3. The health care provider, or the provider group or independent practice
5association of the health care provider, who proposed or who is proposing the
6treatment that is being reviewed.
SB246,12,87 4. The institution at which the treatment being reviewed was or would be
8provided.
SB246,12,99 5. The enrollee or his or her authorized representative.
SB246,12,1010 6. The development or manufacture of the treatment being reviewed.
SB246,12,1411 (g) An independent review organization shall have in operation a quality
12assurance mechanism to ensure the timeliness and quality of the reviews, the
13qualifications and independence of the expert reviewers and the confidentiality of
14the medical records and review materials.
SB246,12,17 15(8) Rule making and reporting. (a) The commissioner shall promulgate rules
16for the implementation and operation of this section, including rules related to
17standards for certifying and recertifying independent review organizations.
SB246,12,1918 (b) The commissioner shall provide a current listing of certified independent
19review organizations to all of the following:
SB246,12,2120 1. Every limited service health organization, preferred provider plan and
21managed care plan that is subject to this section, at least quarterly.
SB246,12,2222 2. Any person who requests a copy of the listing.
SB246,12,2523 (c) The commissioner shall submit to the legislature under s. 13.172 (2) and to
24the governor an annual report on the operation of the independent review system
25under this section.
SB246, s. 6
1Section 6 . Nonstatutory provisions.
SB246,13,112 (1) Rules regarding independent review. Using the procedure under section
3227.24 of the statutes, the commissioner of insurance may promulgate rules required
4under section 609.16 (8) (a) of the statutes, as created by this act, for the period before
5the effective date of the permanent rules promulgated under section 609.16 (8) (a)
6of the statutes, as created by this act, but not to exceed the period authorized under
7section 227.24 (1) (c) and (2) of the statutes. Notwithstanding section 227.24 (1) (a),
8(2) (b) and (3) of the statutes, the commissioner is not required to provide evidence
9that promulgating a rule under this subsection as an emergency rule is necessary for
10the preservation of the public peace, health, safety or welfare and is not required to
11provide a finding of emergency for a rule promulgated under this subsection.
SB246, s. 7 12Section 7. Effective dates. This act takes effect on the first day of the 13th
13month beginning after publication, except as follows:
SB246,13,1514 (1) The treatment of section 609.16 (8) (a) of the statutes and Section 6 of this
15act take effect on the day after publication.
SB246,13,1616 (End)
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