SB269, s. 19 19Section 19. 632.83 of the statutes is created to read:
SB269,6,24 20632.83 Internal grievance procedure. (1) In this section, "health benefit
21plan" has the meaning given in s. 632.745 (11), except that "health benefit plan"
22includes the coverage specified in s. 632.745 (11) (b) 10. and includes a policy,
23certificate or contract under s. 632.745 (11) (b) 9. that provides only limited-scope
24dental or vision benefits.
SB269,6,25 25(2) Every insurer that issues a health benefit plan shall do all of the following:
SB269, s. 20
1Section 20. 632.835 of the statutes is created to read:
SB269,7,3 2632.835 Independent review of adverse and experimental treatment
3determinations.
(1) Definitions. In this section:
SB269,7,54 (a) "Adverse determination" means a determination by or on behalf of an
5insurer that issues a health benefit plan to which all of the following apply:
SB269,7,76 1. An admission to a health care facility, the availability of care, the continued
7stay or other treatment that is a covered benefit has been reviewed.
SB269,7,108 2. Based on the information provided, the treatment under subd. 1. does not
9meet the health benefit plan's requirements for medical necessity, appropriateness,
10health care setting, level of care or effectiveness.
SB269,7,1311 3. Based on the information provided, the insurer that issued the health benefit
12plan reduced, denied or terminated the treatment under subd. 1. or payment for the
13treatment under subd. 1.
SB269,7,1614 4. Subject to sub. (5) (c), the amount of the reduction or the cost or expected cost
15of the denied or terminated treatment or payment exceeds, or will exceed during the
16course of the treatment, $500.
SB269,7,1917 (b) "Experimental treatment determination" means a determination by or on
18behalf of an insurer that issues a health benefit plan to which all of the following
19apply:
SB269,7,2020 1. A proposed treatment has been reviewed.
SB269,7,2221 2. Based on the information provided, the treatment under subd. 1. is
22determined to be experimental under the terms of the health benefit plan.
SB269,7,2523 3. Based on the information provided, the insurer that issued the health benefit
24plan denied the treatment under subd. 1. or payment for the treatment under subd.
251.
SB269,8,2
14. Subject to sub. (5) (c), the cost or expected cost of the denied treatment or
2payment exceeds, or will exceed during the course of the treatment, $500.
SB269,8,43 (c) "Health benefit plan" has the meaning given in s. 632.745 (11), except that
4"health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 10.
SB269,8,65 (d) "Treatment" means a medical service, diagnosis, procedure, therapy, drug
6or device.
SB269,8,11 7(2) Review requirements; who may conduct. (a) Every insurer that issues a
8health benefit plan shall establish an independent review procedure whereby an
9insured under the health benefit plan, or his or her authorized representative, may
10request and obtain an independent review of an adverse determination or an
11experimental treatment determination made with respect to the insured.
SB269,8,1912 (b) Whenever an adverse determination or an experimental treatment
13determination is made, the insurer involved in the determination shall provide
14notice to the insured of the insured's right to obtain the independent review required
15under this section, how to request the review and the time within which the review
16must be requested. The notice shall include a current listing of independent review
17organizations certified under sub. (4). An independent review under this section
18may be conducted only by an independent review organization certified under sub.
19(4) and selected by the insured.
SB269,8,2520 (c) Except as provided in par. (d), an insured must exhaust the internal
21grievance procedure under s. 632.83 before the insured may request an independent
22review under this section. Except as provided in sub. (9), an insured who uses the
23internal grievance procedure must request an independent review as provided in
24sub. (3) (a) within 4 months after the insured receives notice of the disposition of his
25or her grievance under s. 632.83 (3) (d).
SB269,9,3
1(d) An insured is not required to exhaust the internal grievance procedure
2under s. 632.83 before requesting an independent review if any of the following
3apply:
SB269,9,54 1. The insured and the insurer agree that the matter may proceed directly to
5independent review under sub. (3).
SB269,9,126 2. Along with the notice to the insurer of the request for independent review
7under sub. (3) (a), the insured submits to the independent review organization
8selected by the insured a request to bypass the internal grievance procedure under
9s. 632.83 and the independent review organization determines that the health
10condition of the insured is such that requiring the insured to use the internal
11grievance procedure before proceeding to independent review would jeopardize the
12life or health of the insured or the insured's ability to regain maximum function.
SB269,9,24 13(3) Procedure. (a) To request an independent review, an insured or his or her
14authorized representative shall provide timely written notice of the request for
15independent review, and of the independent review organization selected, to the
16insurer that made or on whose behalf was made the adverse or experimental
17treatment determination. The insurer shall immediately notify the commissioner
18and the independent review organization selected by the insured of the request for
19independent review. The insured or his or her authorized representative must pay
20a $50 fee to the independent review organization. If the insured prevails on the
21review, in whole or in part, the entire amount paid by the insured or his or her
22authorized representative shall be refunded by the insurer to the insured or his or
23her authorized representative. For each independent review in which it is involved,
24an insurer shall pay a fee to the independent review organization.
SB269,10,3
1(b) Within 3 business days after receiving written notice of a request for
2independent review under par. (a), the insurer shall submit to the independent
3review organization copies of all of the following:
SB269,10,54 1. Any information submitted to the insurer by the insured in support of the
5insured's position in the internal grievance under s. 632.83.
SB269,10,76 2. The contract provisions or evidence of coverage of the insured's health benefit
7plan.
SB269,10,98 3. Any other relevant documents or information used by the insurer in the
9internal grievance determination under s. 632.83.
SB269,10,1510 (c) Within 5 business days after receiving the information under par. (b), the
11independent review organization shall request any additional information that it
12requires for the review from the insured or the insurer. Within 5 business days after
13receiving a request for additional information, the insured or the insurer shall
14submit the information or an explanation of why the information is not being
15submitted.
SB269,10,1816 (d) An independent review under this section may not include appearances by
17the insured or his or her authorized representative, any person representing the
18health benefit plan or any witness on behalf of either the insured or the insurer.
SB269,11,319 (e) In addition to the information under pars. (b) and (c), the independent
20review organization may accept for consideration any typed or printed, verifiable
21medical or scientific evidence that the independent review organization determines
22is relevant, regardless of whether the evidence has been submitted for consideration
23at any time previously. The insurer and the insured shall submit to the other party
24to the independent review any information submitted to the independent review
25organization under this paragraph and pars. (b) and (c). If, on the basis of any

1additional information, the insurer reconsiders the insured's grievance and
2determines that the treatment that was the subject of the grievance should be
3covered, the independent review is terminated.
SB269,11,114 (f) If the independent review is not terminated under par. (e), the independent
5review organization shall, within 30 business days after the expiration of all time
6limits that apply in the matter, make a decision on the basis of the documents and
7information submitted under this subsection. The decision shall be in writing,
8signed on behalf of the independent review organization and served by personal
9delivery or by mailing a copy to the insured or his or her authorized representative
10and to the insurer. A decision of an independent review organization is binding on
11the insured and the insurer.
SB269,11,1612 (g) If the independent review organization determines that the health
13condition of the insured is such that following the procedure outlined in pars. (b) to
14(f) would jeopardize the life or health of the insured or the insured's ability to regain
15maximum function, the procedure outlined in pars. (b) to (f) shall be followed with
16the following differences:
SB269,11,1817 1. The insurer shall submit the information under par. (b) within one day after
18receiving the notice of the request for independent review under par. (a).
SB269,11,2119 2. The independent review organization shall request any additional
20information under par. (c) within 2 business days after receiving the information
21under par. (b).
SB269,11,2422 3. The insured or insurer shall, within 2 days after receiving a request under
23par. (c), submit any information requested or an explanation of why the information
24is not being submitted.
SB269,12,3
14. The independent review organization shall make its decision under par. (f)
2within 72 hours after the expiration of the time limits under this paragraph that
3apply in the matter.
SB269,12,6 4(3m) Standards for decisions. (a) A decision of an independent review
5organization regarding an adverse determination must be consistent with the terms
6of the health benefit plan under which the adverse determination was made.
SB269,12,117 (b) A decision of an independent review organization regarding an
8experimental treatment determination is limited to a determination of whether the
9proposed treatment is experimental. The independent review organization shall
10determine that the treatment is not experimental and find in favor of the insured
11only if the independent review organization finds all of the following:
SB269,12,1412 1. The treatment has been approved by the federal food and drug
13administration, if the treatment is subject to the approval of the federal food and
14drug administration.
SB269,12,1615 2. Medically and scientifically accepted evidence clearly demonstrates that the
16treatment meets all of the following criteria:
SB269,12,1717 a. The treatment is proven safe.
SB269,12,1818 am. The treatment is proven effective for the insured's condition.
SB269,12,2019 b. The treatment can be expected to produce greater benefits than the standard
20treatment without posing a greater adverse risk to the insured.
SB269,12,2221 c. The treatment meets the coverage terms of the health benefit plan and is not
22specifically excluded under the terms of the health benefit plan.
SB269,13,3 23(4) Certification of independent review organizations. (a) The commissioner
24shall certify independent review organizations. An independent review
25organization must demonstrate to the satisfaction of the commissioner that it is

1unbiased, as defined by the commissioner by rule. An organization certified under
2this paragraph must be recertified on a biennial basis to continue to provide
3independent review services under this section.
SB269,13,74 (ag) An independent review organization shall have in operation a quality
5assurance mechanism to ensure the timeliness and quality of the independent
6reviews, the qualifications and independence of the clinical peer reviewers and the
7confidentiality of the medical records and review materials.
SB269,13,138 (ap) An independent review organization shall establish reasonable fees that
9it will charge for independent reviews and shall submit its fee schedule to the
10commissioner for a determination of reasonableness and for approval. An
11independent review organization may not change any fees approved by the
12commissioner more than once per year and shall submit any proposed fee changes
13to the commissioner for approval.
SB269,13,1814 (b) An organization applying for certification or recertification as an
15independent review organization shall pay the applicable fee under s. 601.31 (1) (Lp)
16or (Lr). Every organization certified or recertified as an independent review
17organization shall file a report with the commissioner in accordance with rules
18promulgated under sub. (5) (a) 4.
SB269,13,2219 (c) The commissioner may examine, audit or accept an audit of the books and
20records of an independent review organization as provided for examination of
21licensees and permittees under s. 601.43 (1), (3), (4) and (5), to be conducted as
22provided in s. 601.44, and with costs to be paid as provided in s. 601.45.
SB269,14,623 (d) The commissioner may revoke, suspend or limit in whole or in part the
24certification of an independent review organization, or may refuse to recertify an
25independent review organization, if the commissioner finds that the independent

1review organization is unqualified or has violated an insurance statute or rule or a
2valid order of the commissioner under s. 601.41 (4), or if the independent review
3organization's methods or practices in the conduct of its business endanger, or its
4financial resources are inadequate to safeguard, the legitimate interests of
5consumers and the public. The commissioner may summarily suspend an
6independent review organization's certification under s. 227.51 (3).
SB269,14,87 (e) The commissioner shall keep an up-to-date listing of certified independent
8review organizations and shall provide a copy of the listing to all of the following:
SB269,14,99 1. Every insurer that is subject to this section, at least quarterly.
SB269,14,1010 2. Any person who requests a copy of the listing.
SB269,14,13 11(5) Rules; report; adjustments. (a) The commissioner shall promulgate rules
12for the independent review required under this section. The rules shall include at
13least all of the following:
SB269,14,1514 1. The application procedures for certification and recertification as an
15independent review organization.
SB269,14,1816 2. The standards that the commissioner will use for certifying and recertifying
17organizations as independent review organizations, including standards for
18determining whether an independent review organization is unbiased.
SB269,14,2019 3. Procedures and processes, in addition to those in sub. (3), that independent
20review organizations must follow.
SB269,14,2221 4. What must be included in the report required under sub. (4) and the
22frequency with which the report must be filed with the commissioner.
SB269,14,2423 5. Standards for the practices and conduct of independent review
24organizations.
SB269,15,2
16. Standards, in addition to those in sub. (6), addressing conflicts of interest by
2independent review organizations.
SB269,15,63 (b) The commissioner shall annually submit a report to the legislature under
4s. 13.172 (2) that specifies the number of independent reviews requested under this
5section in the preceding year, the insurers and health benefit plans involved in the
6independent reviews and the dispositions of the independent reviews.
SB269,15,97 (c) To reflect changes in the consumer price index for all urban consumers, U.S.
8city average, as determined by the U.S. department of labor, the commissioner shall
9at least annually adjust the amounts specified in sub. (1) (a) 4. and (b) 4.
SB269,15,11 10(6) Conflict of interest standards. (a) An independent review organization
11may not be affiliated with any of the following:
SB269,15,1212 1. A health benefit plan.
SB269,15,1413 2. A national, state or local trade association of health benefit plans, or an
14affiliate of any such association.
SB269,15,1615 3. A national, state or local trade association of health care providers, or an
16affiliate of any such association.
SB269,15,2017 (b) An independent review organization appointed to conduct an independent
18review and a clinical peer reviewer assigned by an independent review organization
19to conduct an independent review may not have a material professional, familial or
20financial interest with any of the following:
SB269,15,2221 1. The insurer that issued the health benefit plan that is the subject of the
22independent review.
SB269,15,2423 2. Any officer, director or management employe of the insurer that issued the
24health benefit plan that is the subject of the independent review.
SB269,16,3
13. The health care provider that recommended or provided the health care
2service or treatment that is the subject of the independent review, or the health care
3provider's medical group or independent practice association.
SB269,16,54 4. The facility at which the health care service or treatment that is the subject
5of the independent review was or would be provided.
SB269,16,76 5. The developer or manufacturer of the principal procedure, equipment, drug
7or device that is the subject of the independent review.
SB269,16,88 6. The insured or his or her authorized representative.
SB269,16,11 9(6m) Qualifications of clinical peer reviewers. A clinical peer reviewer who
10conducts a review on behalf of a certified independent review organization must
11satisfy all of the following requirements:
SB269,16,1412 (a) Be a health care provider who is expert in treating the medical condition
13that is the subject of the review and who is knowledgeable about the treatment that
14is the subject of the review through current, actual clinical experience.
SB269,16,2015 (b) Hold a credential, as defined in s. 440.01 (2) (a), that is not limited or
16restricted; or hold a license, certificate, registration or permit that authorizes or
17qualifies the health care provider to perform acts substantially the same as those
18acts authorized by a credential, as defined in s. 440.01 (2) (a), that was issued by a
19governmental authority in a jurisdiction outside this state and that is not limited or
20restricted.
SB269,16,2221 (c) If a physician, hold a current certification by a recognized American medical
22specialty board in the area or areas appropriate to the subject of the review.
SB269,16,2523 (d) Have no history of disciplinary sanctions, including loss of staff privileges,
24taken or pending by the medical examining board or another regulatory body or by
25any hospital or government.
SB269,17,6
1(7) Immunity. (a) A certified independent review organization is immune from
2any civil or criminal liability that may result because of an independent review
3determination made under this section. An employe, agent or contractor of a
4certified independent review organization is immune from civil liability and criminal
5prosecution for any act or omission done in good faith within the scope of his or her
6powers and duties under this section.
SB269,17,107 (b) A health benefit plan that is the subject of an independent review and the
8insurer that issued the health benefit plan shall not be liable in damages to any
9person for complying with any decision rendered by a certified independent review
10organization during or at the completion of an independent review.
SB269,17,17 11(8) Notice of sufficient independent review organizations. The
12commissioner shall make a determination that at least one independent review
13organization has been certified under sub. (4) that is able to effectively provide the
14independent reviews required under this section and shall publish a notice in the
15Wisconsin Administrative Register that states a date that is 2 months after the
16commissioner makes that determination. The date stated in the notice shall be the
17date on which the independent review procedure under this section begins operating.
SB269,18,3 18(9) Applicability. The independent review required under this section shall be
19available to an insured who receives notice of the disposition of his or her grievance
20under s. 632.83 (3) (d) on or after the first day of the 7th month beginning after the
21effective date of this subsection .... [revisor inserts date]. Notwithstanding sub. (2)
22(c), an insured who receives notice of the disposition of his or her grievance under s.
23632.83 (3) (d) on or after the first day of the 7th month beginning after the effective
24date of this subsection .... [revisor inserts date], but before the date stated in the
25notice published by the commissioner in the Wisconsin Administrative Register

1under sub. (8) .... [revisor inserts date], must request an independent review no later
2than 4 months after the date stated in the notice published by the commissioner in
3the Wisconsin Administrative Register under sub. (8) .... [revisor inserts date].
SB269, s. 21 4Section 21 . Nonstatutory provisions.
SB269,18,95 (1) Rules regarding independent review. The commissioner of insurance shall
6submit in proposed form the rules required under section 632.835 (5) (a) of the
7statutes, as created by this act, to the legislative council staff under section 227.15
8(1) of the statutes no later than the first day of the 7th month beginning after the
9effective date of this paragraph.
SB269, s. 22 10Section 22. Effective dates. This act takes effect on the day after publication,
11except as follows:
SB269,18,1412 (1) The treatment of sections 609.15 (title), (1) (intro.), (a), (b) and (c) and (2)
13(intro.), (a), (b), (c), (d) and (e), 609.655 (4) (b) and 632.83 of the statutes takes effect
14on the first day of the 7th month beginning after publication.
SB269,18,1815 (2) The treatment of section 632.835 (2), (3), (3m) and (5) (b) and (c) of the
16statutes takes effect on the date stated in the notice published by the commissioner
17of insurance in the Wisconsin Administrative Register under section 632.835 (8) of
18the statutes, as created by this act.
SB269,18,1919 (End)
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