AB518-ASA1,10,1817 2. Medically and scientifically accepted evidence clearly demonstrates that the
18treatment meets all of the following criteria:
AB518-ASA1,10,1919 a. The treatment is proven safe.
AB518-ASA1,10,2120 b. The treatment can be expected to produce greater benefits than the standard
21treatment without posing a greater adverse risk to the insured.
AB518-ASA1,10,2322 c. The treatment meets the coverage terms of the health benefit plan and is not
23specifically excluded under the terms of the health benefit plan.
AB518-ASA1,11,4 24(4) Certification of independent review organizations. (a) The commissioner
25shall certify independent review organizations. An independent review

1organization must demonstrate to the satisfaction of the commissioner that it is
2unbiased, as defined by the commissioner by rule. An organization certified under
3this paragraph must be recertified on a biennial basis to continue to provide
4independent review services under this section.
AB518-ASA1,11,85 (ag) An independent review organization shall have in operation a quality
6assurance mechanism to ensure the timeliness and quality of the independent
7reviews, the qualifications and independence of the clinical peer reviewers and the
8confidentiality of the medical records and review materials.
AB518-ASA1,11,139 (ap) An independent review organization shall determine the fees that it will
10charge for independent reviews and submit its fee schedule to the commissioner for
11approval. An independent review organization may not change any fees approved
12by the commissioner more than once per year and shall submit any proposed fee
13changes to the commissioner for approval.
AB518-ASA1,11,1814 (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.
AB518-ASA1,11,2219 (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.
AB518-ASA1,12,623 (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).
AB518-ASA1,12,87 (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:
AB518-ASA1,12,99 1. Every insurer that is subject to this section, at least quarterly.
AB518-ASA1,12,1010 2. Any person who requests a copy of the listing.
AB518-ASA1,12,13 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:
AB518-ASA1,12,1514 1. The application procedures for certification and recertification as an
15independent review organization.
AB518-ASA1,12,1816 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.
AB518-ASA1,12,2019 3. Procedures and processes, in addition to those in sub. (3), that independent
20review organizations must follow.
AB518-ASA1,12,2221 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.
AB518-ASA1,12,2423 5. Standards for the practices and conduct of independent review
24organizations.
AB518-ASA1,13,2
16. Standards, in addition to those in sub. (6), addressing conflicts of interest by
2independent review organizations.
AB518-ASA1,13,63 (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.
AB518-ASA1,13,97 (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.
AB518-ASA1,13,11 10(6) Conflict of interest standards. (a) An independent review organization
11may not be affiliated with any of the following:
AB518-ASA1,13,1212 1. A health benefit plan.
AB518-ASA1,13,1413 2. A national, state or local trade association of health benefit plans, or an
14affiliate of any such association.
AB518-ASA1,13,1615 3. A national, state or local trade association of health care providers, or an
16affiliate of any such association.
AB518-ASA1,13,2017 (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:
AB518-ASA1,13,2221 1. The insurer that issued the health benefit plan that is the subject of the
22independent review.
AB518-ASA1,13,2423 2. Any officer, director or management employe of the insurer that issued the
24health benefit plan that is the subject of the independent review.
AB518-ASA1,14,3
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.
AB518-ASA1,14,54 4. The facility at which the health care service or treatment that is the subject
5of the independent review was or would be provided.
AB518-ASA1,14,76 5. The developer or manufacturer of the principal procedure, equipment, drug
7or device that is the subject of the independent review.
AB518-ASA1,14,88 6. The insured or his or her authorized representative.
AB518-ASA1,14,11 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:
AB518-ASA1,14,1412 (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.
AB518-ASA1,14,2015 (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.
AB518-ASA1,14,2221 (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.
AB518-ASA1,14,2523 (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.
AB518-ASA1,15,6
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.
AB518-ASA1,15,107 (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.
AB518-ASA1,15,17 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.
AB518-ASA1,16,3 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].
AB518-ASA1, s. 21 4Section 21 . Nonstatutory provisions.
AB518-ASA1,16,95 (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.
AB518-ASA1, s. 22 10Section 22. Effective dates. This act takes effect on the day after publication,
11except as follows:
AB518-ASA1,16,1412 (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.
AB518-ASA1,16,1815 (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.
Loading...
Loading...