AB518-ASA2,13,1717
2. Any person who requests a copy of the listing.
AB518-ASA2,13,20
18(5) Rules; report; adjustments. (a) The commissioner shall promulgate rules
19for the independent review required under this section. The rules shall include at
20least all of the following:
AB518-ASA2,13,2221
1. The application procedures for certification and recertification as an
22independent review organization.
AB518-ASA2,13,2523
2. The standards that the commissioner will use for certifying and recertifying
24organizations as independent review organizations, including standards for
25determining whether an independent review organization is unbiased.
AB518-ASA2,14,2
13. Procedures and processes, in addition to those in sub. (3), that independent
2review organizations must follow.
AB518-ASA2,14,43
4. What must be included in the report required under sub. (4) and the
4frequency with which the report must be filed with the commissioner.
AB518-ASA2,14,65
5. Standards for the practices and conduct of independent review
6organizations.
AB518-ASA2,14,87
6. Standards, in addition to those in sub. (6), addressing conflicts of interest by
8independent review organizations.
AB518-ASA2,14,129
(b) The commissioner shall annually submit a report to the legislature under
10s. 13.172 (2) that specifies the number of independent reviews requested under this
11section in the preceding year, the insurers and health benefit plans involved in the
12independent reviews and the dispositions of the independent reviews.
AB518-ASA2,14,1513
(c) To reflect changes in the consumer price index for all urban consumers, U.S.
14city average, as determined by the U.S. department of labor, the commissioner shall
15at least annually adjust the amounts specified in sub. (1) (a) 4. and (b) 4.
AB518-ASA2,14,17
16(6) Conflict of interest standards. (a) An independent review organization
17may not be affiliated with any of the following:
AB518-ASA2,14,1818
1. A health benefit plan.
AB518-ASA2,14,2019
2. A national, state or local trade association of health benefit plans, or an
20affiliate of any such association.
AB518-ASA2,14,2221
3. A national, state or local trade association of health care providers, or an
22affiliate of any such association.
AB518-ASA2,15,223
(b) An independent review organization appointed to conduct an independent
24review and a clinical peer reviewer assigned by an independent review organization
1to conduct an independent review may not have a material professional, familial or
2financial interest with any of the following:
AB518-ASA2,15,43
1. The insurer that issued the health benefit plan that is the subject of the
4independent review.
AB518-ASA2,15,65
2. Any officer, director or management employe of the insurer that issued the
6health benefit plan that is the subject of the independent review.
AB518-ASA2,15,97
3. The health care provider that recommended or provided the health care
8service or treatment that is the subject of the independent review, or the health care
9provider's medical group or independent practice association.
AB518-ASA2,15,1110
4. The facility at which the health care service or treatment that is the subject
11of the independent review was or would be provided.
AB518-ASA2,15,1312
5. The developer or manufacturer of the principal procedure, equipment, drug
13or device that is the subject of the independent review.
AB518-ASA2,15,1414
6. The insured or his or her authorized representative.
AB518-ASA2,15,17
15(6m) Qualifications of clinical peer reviewers. A clinical peer reviewer who
16conducts a review on behalf of a certified independent review organization must
17satisfy all of the following requirements:
AB518-ASA2,15,2018
(a) Be a health care provider who is expert in treating the medical condition
19that is the subject of the review and who is knowledgeable about the treatment that
20is the subject of the review through current, actual clinical experience.
AB518-ASA2,16,221
(b) Hold a credential, as defined in s. 440.01 (2) (a), that is not limited or
22restricted; or hold a license, certificate, registration or permit that authorizes or
23qualifies the health care provider to perform acts substantially the same as those
24acts authorized by a credential, as defined in s. 440.01 (2) (a), that was issued by a
1governmental authority in a jurisdiction outside this state and that is not limited or
2restricted.
AB518-ASA2,16,43
(c) If a physician, hold a current certification by a recognized American medical
4specialty board in the area or areas appropriate to the subject of the review.
AB518-ASA2,16,75
(d) Have no history of disciplinary sanctions, including loss of staff privileges,
6taken or pending by the medical examining board or another regulatory body or by
7any hospital or government.
AB518-ASA2,16,13
8(7) Immunity. (a) A certified independent review organization is immune from
9any civil or criminal liability that may result because of an independent review
10determination made under this section. An employe, agent or contractor of a
11certified independent review organization is immune from civil liability and criminal
12prosecution for any act or omission done in good faith within the scope of his or her
13powers and duties under this section.
AB518-ASA2,16,1714
(b) A health benefit plan that is the subject of an independent review and the
15insurer that issued the health benefit plan shall not be liable in damages to any
16person for complying with any decision rendered by a certified independent review
17organization during or at the completion of an independent review.
AB518-ASA2,16,24
18(8) Notice of sufficient independent review organizations. The
19commissioner shall make a determination that at least one independent review
20organization has been certified under sub. (4) that is able to effectively provide the
21independent reviews required under this section and shall publish a notice in the
22Wisconsin Administrative Register that states a date that is 2 months after the
23commissioner makes that determination. The date stated in the notice shall be the
24date on which the independent review procedure under this section begins operating.
AB518-ASA2,17,11
1(9) Applicability. The independent review required under this section shall be
2available to an insured who receives notice of the disposition of his or her grievance
3under s. 632.83 (3) (d) on or after the first day of the 7th month beginning after the
4effective date of this subsection .... [revisor inserts date]. Notwithstanding sub. (2)
5(c), an insured who receives notice of the disposition of his or her grievance under s.
6632.83 (3) (d) on or after the first day of the 7th month beginning after the effective
7date of this subsection .... [revisor inserts date], but before the date stated in the
8notice published by the commissioner in the Wisconsin Administrative Register
9under sub. (8) .... [revisor inserts date], must request an independent review no later
10than 4 months after the date stated in the notice published by the commissioner in
11the Wisconsin Administrative Register under sub. (8) .... [revisor inserts date].
AB518-ASA2,17,1713
(1)
Rules regarding independent review. The commissioner of insurance shall
14submit in proposed form the rules required under section 632.835 (5) (a) of the
15statutes, as created by this act, to the legislative council staff under section 227.15
16(1) of the statutes no later than the first day of the 7th month beginning after the
17effective date of this paragraph.
AB518-ASA2,17,19
19(1) Specialist providers under managed care plans.
AB518-ASA2,17,25
20(a) Except as provided in paragraph (b
), if a policy or certificate that is affected
21by the treatment of sections 609.05 (3) and 609.22 (4) (a) 1., 2. and 3. of the statutes
22contains terms or provisions that are inconsistent with the treatment of sections
23609.05 (3) and 609.22 (4) (a) 1., 2. and 3. of the statutes, the treatment of sections
24609.05 (3) and 609.22 (4) (a) 1., 2. and 3. of the statutes first applies to that policy or
25certificate upon renewal.
AB518-ASA2,18,5
1(b) The treatment of sections 609.05 (3) and 609.22 (4) (a) 1., 2. and 3. of the
2statutes first applies to policies or group certificates covering employes who are
3affected by a collective bargaining agreement containing provisions that are
4inconsistent with the treatment of sections 609.05 (3) and 609.22 (4) (a) 1., 2. and 3.
5of the statutes that are issued or renewed on the earlier of the following:
AB518-ASA2,18,6
61. The day on which the collective bargaining agreement expires.
AB518-ASA2,18,8
72. The day on which the collective bargaining agreement is extended, modified
8or renewed.
AB518-ASA2,18,109
(2)
Lawsuits against managed care plans. The creation of section 609.39 of the
10statutes first applies to claims arising on the effective date of this subsection.
AB518-ASA2, s. 29
11Section
29.
Effective dates. This act takes effect on the day after publication,
12except as follows:
AB518-ASA2,18,1513
(1)
The treatment of sections 609.15 (title), (1) (intro.), (a), (b) and (c) and (2)
14(intro.), (a), (b), (c), (d) and (e), 609.655 (4) (b) and 632.83 of the statutes takes effect
15on the first day of the 7th month beginning after publication.
AB518-ASA2,18,2016
(2)
The treatment of section 632.835 (2), (3), (3m) and (5) (b) and (c) of the
17statutes and the amendment of section 609.39 of the statutes take effect on the date
18stated in the notice published by the commissioner of insurance in the Wisconsin
19Administrative Register under section 632.835 (8) of the statutes, as created by this
20act.