LRBs0384/1
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1999 - 2000 LEGISLATURE
SENATE SUBSTITUTE AMENDMENT 1,
TO 1999 SENATE BILL 350
March 7, 2000 - Offered by Senators Clausing, Rosenzweig, Roessler, Moen and
Burke.
SB350-SSA1,1,8 1An Act to repeal 609.15 (title) and (1) (intro.); to renumber 609.15 (1) (c), 609.15
2(2) (c), 609.15 (2) (d) and 609.15 (2) (e); to renumber and amend 609.15 (1) (a),
3609.15 (1) (b), 609.15 (2) (intro.), 609.15 (2) (a) and 609.15 (2) (b); to amend
440.51 (8), 40.51 (8m), 600.01 (2) (b), 601.42 (4) and 609.655 (4) (b); and to create
5111.91 (2) (s), 601.31 (1) (Lp), 601.31 (1) (Lr), 632.83 and 632.835 of the statutes;
6relating to: requiring insurers to establish internal grievance procedures,
7independent review of certain coverage determinations made by health benefit
8plans and granting rule-making authority.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
SB350-SSA1, s. 1 9Section 1. 40.51 (8) of the statutes is amended to read:
SB350-SSA1,2,210 40.51 (8) Every health care coverage plan offered by the state under sub. (6)
11shall comply with ss. 631.89, 631.90, 631.93 (2), 632.72 (2), 632.746 (1) to (8) and (10),

1632.747, 632.748, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to (5),
2632.895 (5m) and (8) to (13) and 632.896.
SB350-SSA1, s. 2 3Section 2. 40.51 (8m) of the statutes is amended to read:
SB350-SSA1,2,64 40.51 (8m) Every health care coverage plan offered by the group insurance
5board under sub. (7) shall comply with ss. 632.746 (1) to (8) and (10), 632.747,
6632.748, 632.83, 632.835, 632.85, 632.853, 632.855 and 632.895 (11) to (13).
SB350-SSA1, s. 3 7Section 3. 111.91 (2) (s) of the statutes is created to read:
SB350-SSA1,2,108 111.91 (2) (s) The requirements related to internal grievance procedures under
9s. 632.83 and independent review of certain health benefit plan determinations
10under s. 632.835.
SB350-SSA1, s. 4 11Section 4. 600.01 (2) (b) of the statutes is amended to read:
SB350-SSA1,2,1312 600.01 (2) (b) Group or blanket insurance described in sub. (1) (b) 3. and 4. is
13not exempt from ss. 632.745 to 632.749, 632.83 or 632.835 or ch. 633 or 635.
SB350-SSA1, s. 5 14Section 5. 601.31 (1) (Lp) of the statutes is created to read:
SB350-SSA1,2,1615 601.31 (1) (Lp) For certifying as an independent review organization under s.
16632.835, $400.
SB350-SSA1, s. 6 17Section 6. 601.31 (1) (Lr) of the statutes is created to read:
SB350-SSA1,2,1918 601.31 (1) (Lr) For each biennial recertification as an independent review
19organization under s. 632.835, $100.
SB350-SSA1, s. 7 20Section 7. 601.42 (4) of the statutes is amended to read:
SB350-SSA1,3,721 601.42 (4) Replies. Any officer, manager or general agent of any insurer
22authorized to do or doing an insurance business in this state, any person controlling
23or having a contract under which the person has a right to control such an insurer,
24whether exclusively or otherwise, any person with executive authority over or in
25charge of any segment of such an insurer's affairs, any individual practice

1association or officer, director or manager of an individual practice association, any
2insurance agent or other person licensed under chs. 600 to 646, any provider of
3services under a continuing care contract, as defined in s. 647.01 (2), any
4independent review organization certified or recertified under s. 632.835 (4)
or any
5health care provider, as defined in s. 655.001 (8), shall reply promptly in writing or
6in other designated form, to any written inquiry from the commissioner requesting
7a reply.
SB350-SSA1, s. 8 8Section 8. 609.15 (title) and (1) (intro.) of the statutes are repealed.
SB350-SSA1, s. 9 9Section 9. 609.15 (1) (a) of the statutes is renumbered 632.83 (2) (a) and
10amended to read:
SB350-SSA1,3,1411 632.83 (2) (a) Establish and use an internal grievance procedure that is
12approved by the commissioner and that complies with sub. (2) (3) for the resolution
13of enrollees' insureds' grievances with the limited service health organization,
14preferred provider plan or managed care
health benefit plan.
SB350-SSA1, s. 10 15Section 10. 609.15 (1) (b) of the statutes is renumbered 632.83 (2) (b) and
16amended to read:
SB350-SSA1,3,1817 632.83 (2) (b) Provide enrollees insureds with complete and understandable
18information describing the internal grievance procedure under par. (a).
SB350-SSA1, s. 11 19Section 11. 609.15 (1) (c) of the statutes is renumbered 632.83 (2) (c).
SB350-SSA1, s. 12 20Section 12. 609.15 (2) (intro.) of the statutes is renumbered 632.83 (3) (intro.)
21and amended to read:
SB350-SSA1,3,2322 632.83 (3) (intro.) The internal grievance procedure established under sub. (1)
23(2) (a) shall include all of the following elements:
SB350-SSA1, s. 13 24Section 13. 609.15 (2) (a) of the statutes is renumbered 632.83 (3) (a) and
25amended to read:
SB350-SSA1,4,2
1632.83 (3) (a) The opportunity for an enrollee insured to submit a written
2grievance in any form.
SB350-SSA1, s. 14 3Section 14. 609.15 (2) (b) of the statutes is renumbered 632.83 (3) (b) and
4amended to read:
SB350-SSA1,4,85 632.83 (3) (b) Establishment of a grievance panel for the investigation of each
6grievance submitted under par. (a), consisting of at least one individual authorized
7to take corrective action on the grievance and at least one enrollee insured other than
8the grievant, if an enrollee insured is available to serve on the grievance panel.
SB350-SSA1, s. 15 9Section 15. 609.15 (2) (c) of the statutes is renumbered 632.83 (3) (c).
SB350-SSA1, s. 16 10Section 16. 609.15 (2) (d) of the statutes is renumbered 632.83 (3) (d).
SB350-SSA1, s. 17 11Section 17. 609.15 (2) (e) of the statutes is renumbered 632.83 (3) (e).
SB350-SSA1, s. 18 12Section 18. 609.655 (4) (b) of the statutes is amended to read:
SB350-SSA1,4,2013 609.655 (4) (b) Upon completion of the review under par. (a), the medical
14director of the managed care plan shall determine whether the policy or certificate
15will provide coverage of any further treatment for the dependent student's nervous
16or mental disorder or alcoholism or other drug abuse problems that is provided by
17a provider located in reasonably close proximity to the school in which the student
18is enrolled. If the dependent student disputes the medical director's determination,
19the dependent student may submit a written grievance under the managed care
20plan's internal grievance procedure established under s. 609.15 632.83.
SB350-SSA1, s. 19 21Section 19. 632.83 of the statutes is created to read:
SB350-SSA1,5,2 22632.83 Internal grievance procedure. (1) In this section, "health benefit
23plan" has the meaning given in s. 632.745 (11), except that "health benefit plan"
24includes the coverage specified in s. 632.745 (11) (b) 10. and includes a policy,

1certificate or contract under s. 632.745 (11) (b) 9. that provides only limited-scope
2dental or vision benefits.
SB350-SSA1,5,3 3(2) Every insurer that issues a health benefit plan shall do all of the following:
SB350-SSA1, s. 20 4Section 20. 632.835 of the statutes is created to read:
SB350-SSA1,5,6 5632.835 Independent review of adverse and experimental treatment
6determinations.
(1) Definitions. In this section:
SB350-SSA1,5,87 (a) "Adverse determination" means a determination by or on behalf of an
8insurer that issues a health benefit plan to which all of the following apply:
SB350-SSA1,5,109 1. An admission to a health care facility, the availability of care, the continued
10stay or other treatment that is a covered benefit has been reviewed.
SB350-SSA1,5,1311 2. Based on the information provided, the treatment under subd. 1. does not
12meet the health benefit plan's requirements for medical necessity, appropriateness,
13health care setting, level of care or effectiveness.
SB350-SSA1,5,1614 3. Based on the information provided, the insurer that issued the health benefit
15plan reduced, denied or terminated the treatment under subd. 1. or payment for the
16treatment under subd. 1.
SB350-SSA1,5,1917 4. Subject to sub. (5) (c), the amount of the reduction or the cost or expected cost
18of the denied or terminated treatment or payment exceeds, or will exceed during the
19course of the treatment, $250.
SB350-SSA1,5,2220 (b) "Experimental treatment determination" means a determination by or on
21behalf of an insurer that issues a health benefit plan to which all of the following
22apply:
SB350-SSA1,5,2323 1. A proposed treatment has been reviewed.
SB350-SSA1,5,2524 2. Based on the information provided, the treatment under subd. 1. is
25determined to be experimental under the terms of the health benefit plan.
SB350-SSA1,6,3
13. Based on the information provided, the insurer that issued the health benefit
2plan denied the treatment under subd. 1. or payment for the treatment under subd.
31.
SB350-SSA1,6,54 4. Subject to sub. (5) (c), the cost or expected cost of the denied treatment or
5payment exceeds, or will exceed during the course of the treatment, $250.
SB350-SSA1,6,76 (c) "Health benefit plan" has the meaning given in s. 632.745 (11), except that
7"health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 10.
SB350-SSA1,6,98 (d) "Treatment" means a medical service, diagnosis, procedure, therapy, drug
9or device.
SB350-SSA1,6,14 10(2) Review requirements; who may conduct. (a) Every insurer that issues a
11health benefit plan shall establish an independent review procedure whereby an
12insured under the health benefit plan, or his or her authorized representative, may
13request and obtain an independent review of an adverse determination or an
14experimental treatment determination made with respect to the insured.
SB350-SSA1,6,2215 (b) Whenever an adverse determination or an experimental treatment
16determination is made, the insurer involved in the determination shall provide
17notice to the insured of the insured's right to obtain the independent review required
18under this section, how to request the review and the time within which the review
19must be requested. The notice shall include a current listing of independent review
20organizations certified under sub. (4). An independent review under this section
21may be conducted only by an independent review organization certified under sub.
22(4) and selected by the insured.
SB350-SSA1,7,323 (c) Except as provided in par. (d), an insured must exhaust the internal
24grievance procedure under s. 632.83 before the insured may request an independent
25review under this section. Except as provided in sub. (9), an insured who uses the

1internal grievance procedure must request an independent review as provided in
2sub. (3) (a) within 4 months after the insured receives notice of the disposition of his
3or her grievance under s. 632.83 (3) (d).
SB350-SSA1,7,64 (d) An insured is not required to exhaust the internal grievance procedure
5under s. 632.83 before requesting an independent review if any of the following
6apply:
SB350-SSA1,7,87 1. The insured and the insurer agree that the matter may proceed directly to
8independent review under sub. (3).
SB350-SSA1,7,159 2. Along with the notice to the insurer of the request for independent review
10under sub. (3) (a), the insured submits to the independent review organization
11selected by the insured a request to bypass the internal grievance procedure under
12s. 632.83 and the independent review organization determines that the health
13condition of the insured is such that requiring the insured to use the internal
14grievance procedure before proceeding to independent review would jeopardize the
15life or health of the insured or the insured's ability to regain maximum function.
SB350-SSA1,8,2 16(3) Procedure. (a) To request an independent review, an insured or his or her
17authorized representative shall provide timely written notice of the request for
18independent review, and of the independent review organization selected, to the
19insurer that made or on whose behalf was made the adverse or experimental
20treatment determination. The insurer shall immediately notify the commissioner
21and the independent review organization selected by the insured of the request for
22independent review. The insured or his or her authorized representative must pay
23a $25 fee to the independent review organization. If the insured prevails on the
24review, in whole or in part, the entire amount paid by the insured or his or her
25authorized representative shall be refunded by the insurer to the insured or his or

1her authorized representative. For each independent review in which it is involved,
2an insurer shall pay a fee to the independent review organization.
SB350-SSA1,8,53 (b) Within 3 business days after receiving written notice of a request for
4independent review under par. (a), the insurer shall submit to the independent
5review organization copies of all of the following:
SB350-SSA1,8,76 1. Any information submitted to the insurer by the insured in support of the
7insured's position in the internal grievance under s. 632.83.
SB350-SSA1,8,98 2. The contract provisions or evidence of coverage of the insured's health benefit
9plan.
SB350-SSA1,8,1110 3. Any other relevant documents or information used by the insurer in the
11internal grievance determination under s. 632.83.
SB350-SSA1,8,1712 (c) Within 5 business days after receiving the information under par. (b), the
13independent review organization shall request any additional information that it
14requires for the review from the insured or the insurer. Within 5 business days after
15receiving a request for additional information, the insured or the insurer shall
16submit the information or an explanation of why the information is not being
17submitted.
SB350-SSA1,8,2018 (d) An independent review under this section may not include appearances by
19the insured or his or her authorized representative, any person representing the
20health benefit plan or any witness on behalf of either the insured or the insurer.
SB350-SSA1,9,521 (e) In addition to the information under pars. (b) and (c), the independent
22review organization may accept for consideration any typed or printed, verifiable
23medical or scientific evidence that the independent review organization determines
24is relevant, regardless of whether the evidence has been submitted for consideration
25at any time previously. The insurer and the insured shall submit to the other party

1to the independent review any information submitted to the independent review
2organization under this paragraph and pars. (b) and (c). If, on the basis of any
3additional information, the insurer reconsiders the insured's grievance and
4determines that the treatment that was the subject of the grievance should be
5covered, the independent review is terminated.
SB350-SSA1,9,136 (f) If the independent review is not terminated under par. (e), the independent
7review organization shall, within 30 business days after the expiration of all time
8limits that apply in the matter, make a decision on the basis of the documents and
9information submitted under this subsection. The decision shall be in writing,
10signed on behalf of the independent review organization and served by personal
11delivery or by mailing a copy to the insured or his or her authorized representative
12and to the insurer. A decision of an independent review organization is binding on
13the insured and the insurer.
SB350-SSA1,9,1814 (g) If the independent review organization determines that the health
15condition of the insured is such that following the procedure outlined in pars. (b) to
16(f) would jeopardize the life or health of the insured or the insured's ability to regain
17maximum function, the procedure outlined in pars. (b) to (f) shall be followed with
18the following differences:
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