Chapter Ins 18
HEALTH BENEFIT PLAN GRIEVANCES AND INDEPENDENT REVIEW ORGANIZATIONS CERTIFICATION AND REVIEW PROCEDURES
Subchapter I — Definitions
Subchapter II — Grievance Procedures
Ins 18.04 Right of the commissioner to request OCI complaints be handled as grievances.
Ins 18.05 Expedited grievance procedure.
Ins 18.06 Reporting requirements.
Subchapter III — Independent Review Procedures
Ins 18.105 Annual CPI adjustment for independent review eligibility.
Ins 18.11 Independent review.
Ins 18.12 Independent review organization procedures.
Ins 18.13 Standards of independent review.
Ins 18.14 Approval of independent review organizations.
Ins 18.16 Independent review organization reporting requirements.
Ins 18.18 Independent review organization fees.
Ins 18.01
Ins 18.01 Definitions. In this chapter:
Ins 18.01(1)
(1) “Commissioner" means the “commissioner of insurance" of this state or the commissioner's designee.
Ins 18.01(2)
(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.
Ins 18.01(2m)
(2m) “Coverage denial determination" has the meaning as defined in s.
632.835 (1) (ag), Stats., and includes, for individual insurance products, a policy reformation or change in premium charged based upon underwriting or claims information greater than 25% from the premium in effect during the period of contestability except to the extent the modification is due to the applicant's age or a rate increase applied by the insurer to all similar individual policy forms applied uniformly.
Ins 18.01(3)
(3) “Expedited grievance" means a grievance where any of the following applies:
Ins 18.01(3)(a)
(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.
Ins 18.01(3)(b)
(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.
Ins 18.01(3)(c)
(c) A physician with knowledge of the insured's medical condition determines that the grievance shall be treated as an expedited grievance.
Ins 18.01(4)
(4) “Grievance" means any dissatisfaction with 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 including any of the following:
Ins 18.01(4)(c)
(c) Determination of a diagnosis or level of service required for evidence-based treatment of autism spectrum disorders.
Ins 18.01(6)
(6) “Independent review" means a review conducted by a certified independent review organization.
Ins 18.01(8)
(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
.
Ins 18.01(9)
(9) “Office" means the “office of the commissioner of insurance."
Ins 18.01(10)
(10) “Rescission" or “reformation" of a policy means a determination by an insurer offering health benefit plan, subject to s.
628.34 (3), Stats., to withdraw the coverage back to the initial date of coverage, modify the terms of the policy or adjust the premium rate by more than 25% from the premium in effect during the period of contestability. A modification in premium based upon the applicant's or insured's age or a rate increase uniformly applied by the insurer to all similar individual policy forms is not a rescission or reformation of a policy.
Ins 18.01 History
History: CR 00-169: cr.
Register November 2001 No. 551, eff. 12-1-01;
CR 10-023: cr. (2m), (10), am. (4) Register September 2010 No. 657, eff. 10-1-10. Ins 18.02
Ins 18.02 Definitions. In addition to the definitions in s.
632.83, Stats., in this subchapter:
Ins 18.02(1)
(1) “Health benefit plan" has the meaning provided in s.
632.83, Stats., and includes Medicare supplement and Medicare replacement plans as defined in s.
600.03 (28p) and
(28r), Stats., and
s. Ins 3.39 (3) (v) and
(w). Health benefit plan includes Medicare cost and select plans but does not include Medicare Advantage plans.
Ins 18.03(1)
(1)
Definition and explanation of the grievance procedure. Ins 18.03(1)(a)(a) Each insurer offering a health benefit plan shall incorporate within its policies, certificates and outlines of coverage the definition of a grievance as stated in
s. Ins 18.01 (4).
Ins 18.03(1)(b)
(b) An insurer offering a health benefit plan shall develop an internal grievance and expedited grievance procedure that shall be described in each policy and certificate issued to insureds at the time of enrollment or issuance.
Ins 18.03(2)
(2) Notification of right to appeal determinations. Ins 18.03(2)(a)(a) In addition to the requirements under
sub. (1), each time an insurer offering a health benefit plan denies a claim or benefit or initiates disenrollment proceedings, the health benefit plan shall notify the affected insured of the right to file a grievance. For purposes of this subchapter, denial or refusal of an insured's request of the insurer for a referral shall be considered a denial of a claim or benefit.
Ins 18.03(2)(b)
(b) When notifying the insured of their right to grieve the denial, determination, or initiation of disenrollment, an insurer offering a health benefit plan shall either direct the insured to the policy or certificate section that delineates the procedure for filing a grievance or shall describe, in detail, the grievance procedure to the insured. The notification shall also state the specific reason for the denial, determination or initiation of disenrollment.
Ins 18.03(2)(c)1.1. An insurer offering a health benefit plan that is a defined network plan as defined in s.
609.01 (1b), Stats., other than a preferred provider plan as defined in s.
609.01 (4), Stats., shall do all of the following:
Ins 18.03(2)(c)1.a.
a. Include in each contract between it and its providers, provider networks, and within each agreement governing the administration of provider services, a provision that requires the contracting entity to promptly respond to complaints and grievances filed with the insurer to facilitate resolution.
Ins 18.03(2)(c)1.b.
b. Require contracted entities that subcontract for the provision of services, including subcontracts with health care providers, to incorporate within their contracts a requirement that the providers promptly respond to complaints and grievances filed with the insurer to facilitate resolution.
Ins 18.03(2)(c)1.c.
c. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.
Ins 18.03(2)(c)1.d.
d. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.
Ins 18.03(2)(c)2.
2. An insurer offering a health benefit plan that is a preferred provider plan as defined in s.
609.01 (4), Stats., shall do all of the following:
Ins 18.03(2)(c)2.a.
a. Include in each contract between it and its providers, provider networks and within each agreement governing the administration of provider services, a provision that requires the contracting entity to promptly provide the insurer the information necessary to permit the insurer to respond to complaints or grievances described under
subd. 2. c.
Ins 18.03(2)(c)2.b.
b. Require contracted entities that subcontract for the provision of services, to incorporate within their contracts, including subcontracts with health care providers, a requirement that the subcontractor promptly provide the insurer with the information necessary to respond to complaints or grievances described under
subd. 2. c.
Ins 18.03(2)(c)2.c.
c. Include in its description of the grievance process required under
sub. (1), a clear statement that an insured may submit to the insurer offering a health benefit plan a complaint or grievance relating to covered services provided by a participating health care provider.
Ins 18.03(2)(c)2.e.
e. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.
Ins 18.03(2)(c)2.f.
f. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.
Ins 18.03(2)(d)
(d) If the insurer offering a health benefit plan is either a health maintenance organization as defined in s.
609.01 (2), Stats., or a limited service health organization as defined by s.
609.01 (3), Stats., and the insurer initiates disenrollment proceedings, the insurer shall additionally comply with
s. Ins 9.39.
Ins 18.03(3)
(3) Grievance procedure. The grievance procedure utilized by an insurer offering a health benefit plan shall include all of the following:
Ins 18.03(3)(a)
(a) A method whereby the insured who filed the grievance, or the insured's authorized representative, has the right to appear in person before the grievance panel to present written or oral information. The insurer shall permit the grievant to submit written questions to the person or persons responsible for making the determination that resulted in the denial, determination, or initiation of disenrollment unless the insurer permits the insured or insured's authorized representative to meet with and question the decision maker or makers.
Ins 18.03(3)(b)
(b) A written notification to the insured of the time and place of the grievance meeting at least 7 calendar days before the meeting.
Ins 18.03(3)(c)
(c) Reasonable accommodations to allow the insured, or the insured's authorized representative, to participate in the meeting.
Ins 18.03(3)(d)
(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.
Ins 18.03(3)(e)
(e) The insured member of the panel shall not be an employee of the plan, to the extent possible.
Ins 18.03(3)(f)
(f) Consultation with a licensed health care provider with expertise in the field relating to the grievance, if appropriate.
Ins 18.03(3)(g)
(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.
Ins 18.03(4)
(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.
Ins 18.03(5)(a)(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:
Ins 18.03(5)(a)1.
1. The person is authorized by law to act on behalf of the insured.
Ins 18.03(5)(a)2.
2. The insured is unable to give consent and the person is a spouse, family member or the treating provider.
Ins 18.03(5)(a)3.
3. The grievance is an expedited grievance and the person represents that the insured has verbally given authorization to represent the insured.
Ins 18.03(5)(b)
(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:
Ins 18.03(5)(b)1.
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.
Ins 18.03(5)(b)3.
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.
Ins 18.03(5)(c)
(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.
Ins 18.03(5)(d)
(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
146.84, 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.
Ins 18.03(6)
(6) Resolution of a grievance. An insurer offering a health benefit plan shall resolve a grievance:
