AB518,7,1212 1. A proposed treatment has been reviewed.
AB518,7,1413 2. Based on the information provided, the treatment under subd. 1. is
14determined to be experimental under the terms of the health benefit plan.
AB518,7,1615 3. Based on the information provided, the health benefit plan denied the
16treatment under subd. 1. or payment for the treatment under subd. 1.
AB518,7,1817 4. Subject to sub. (5) (c), the value of the denied treatment or payment exceeds
18$500, excluding deductibles and copayments.
AB518,7,2019 (c) "Health benefit plan" has the meaning given in s. 632.745 (11), except that
20"health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 10.
AB518,7,25 21(2) Review requirements; who may conduct. (a) Every health benefit plan
22shall establish an independent review procedure whereby an insured under the
23health benefit plan, or his or her authorized representative, may request and obtain
24an independent review of an adverse determination or an experimental treatment
25determination made with respect to the insured.
AB518,8,10
1(b) An independent review under this section may be conducted only by an
2independent review organization certified under sub. (4). Every insurer issuing a
3health benefit plan shall contract with one or more independent review
4organizations certified under sub. (4) for the purpose of conducting independent
5reviews of adverse determinations and experimental treatment determinations
6made by or on behalf of the health benefit plan. The term of a contract with an
7independent review organization may not be less than 2 years. If an insurer fails to
8renew the contract of an independent review organization at the end of the contract
9term, the insurer shall inform the commissioner that the contract has not been
10renewed and of the reasons for the nonrenewal.
AB518,8,1711 (c) An insured must exhaust the health benefit plan's internal grievance
12procedure before the insured may request an independent review under this section,
13unless the delay will result for the insured in serious injury or impairment or a
14life-threatening condition, as determined by the insured's treating health care
15provider. Except as provided in sub. (9), an insured must request an independent
16review as provided in sub. (3) (a) within 4 months after the insured receives notice
17of the disposition of his or her grievance under s. 632.83 (3) (d).
AB518,8,2218 (d) Whenever an adverse determination or an experimental treatment
19determination is made, the health benefit plan involved in the determination shall
20advise the insured of the insured's right to obtain the independent review required
21under this section, how to request the review and the time within which the review
22must be requested.
AB518,9,10 23(3) Procedure. (a) To request an independent review, an insured or his or her
24authorized representative shall provide timely written notice of the request for
25independent review to the health benefit plan that made or on whose behalf was

1made the adverse or experimental treatment determination. The health benefit plan
2shall immediately notify the commissioner of the request for independent review and
3notify the insured of the name and address of the independent review organization
4that will be conducting the review. The insured or his or her authorized
5representative must pay a $50 fee to the independent review organization. If the
6insured prevails on the review, in whole or in part, the entire amount paid by the
7insured or his or her authorized representative shall be refunded by the health
8benefit plan to the insured or his or her authorized representative. For each
9independent review in which it is involved, a health benefit plan shall pay a fee to
10the independent review organization.
AB518,9,1311 (b) Within 3 business days after receiving written notice of a request for
12independent review under par. (a), the health benefit plan shall submit to the
13independent review organization copies of all of the following:
AB518,9,1514 1. Any information submitted to the health benefit plan by the insured in
15support of the insured's position in the internal grievance under s. 632.83.
AB518,9,1616 2. The contract provisions or evidence of coverage of the health benefit plan.
AB518,9,1817 3. Any other relevant documents or information used by the health benefit plan
18in the internal grievance determination under s. 632.83.
AB518,9,2419 (c) Within 5 business days after receiving the information under par. (b), the
20independent review organization shall request any additional information that it
21requires for the review from the insured or the health benefit plan. Within 5 business
22days after receiving a request for additional information, the insured or health
23benefit plan shall submit the information or an explanation of why the information
24is not being submitted.
AB518,10,7
1(d) In addition to the information under pars. (b) and (c), the independent
2review organization may accept for consideration any typed or printed, verifiable
3medical or scientific evidence that the independent review organization determines
4is relevant, regardless of whether the evidence has been submitted for consideration
5at any time previously. The health benefit plan and the insured shall submit to the
6other party to the independent review any information submitted to the independent
7review organization under pars. (b) to (d).
AB518,10,118 (e) An independent review under this section may not include appearances by
9the insured or his or her authorized representative, any person representing the
10health benefit plan or any witness on behalf of either the insured or the health benefit
11plan.
AB518,10,1912 (f) The independent review organization shall, within 30 business days after
13the expiration of all time limits that apply in the matter, make a decision on the basis
14of the documents and information submitted under this subsection. The decision
15shall be in writing, signed on behalf of the independent review organization and
16served by personal delivery or by mailing a copy to the insured or his or her
17authorized representative and to the health benefit plan. A decision of an
18independent review organization is binding on the insured and the health benefit
19plan.
AB518,10,2320 (g) If, in the judgment of the insured's treating health care provider, the adverse
21or experimental treatment determination relates to a serious injury or impairment
22or a life-threatening condition, the procedure outlined in pars. (b) to (f) shall be
23followed with the following differences:
AB518,11,3
11. The health benefit plan shall submit the information under par. (b) within
2one day after receiving the notice of the request for independent review under par.
3(a).
AB518,11,64 2. The independent review organization shall request any additional
5information under par. (c) within 2 business days after receiving the information
6under par. (b).
AB518,11,97 3. The insured or health benefit plan shall, within 2 days after receiving a
8request under par. (c), submit any information requested or an explanation of why
9the information is not being submitted.
AB518,11,1210 4. The independent review organization shall make its decision under par. (f)
11within 72 hours after the expiration of the time limits under this paragraph that
12apply in the matter.
AB518,11,15 13(3m) Standards for decisions. (a) A decision of an independent review
14organization regarding an adverse determination must be consistent with the terms
15of the health benefit plan under which the adverse determination was made.
AB518,11,2016 (b) A decision of an independent review organization regarding an
17experimental treatment determination is limited to a determination of whether the
18proposed treatment is experimental. The independent review organization shall
19determine that the treatment is not experimental and find in favor of the insured
20only if the independent review organization finds all of the following:
AB518,11,2321 1. The insured has a terminal condition, or the insured's ability to regain or
22maintain maximum function would be impaired by withholding the proposed
23treatment.
AB518,12,3
12. The insured has a condition for which standard treatment would not be
2medically indicated for the insured or for which there is no standard treatment
3available that would be as beneficial for the insured as the proposed treatment.
AB518,12,64 3. Scientifically valid studies using accepted protocols and published in peer
5reviewed literature demonstrate that the proposed treatment is likely to be more
6beneficial for the insured than available standard treatment.
AB518,12,97 4. The proposed treatment is not specifically excluded under the terms of the
8health benefit plan and would be covered except for the determination that the
9treatment is experimental for the insured's condition.
AB518,12,15 10(4) Certification of independent review organizations. (a) The commissioner
11shall certify independent review organizations. An independent review
12organization must demonstrate to the satisfaction of the commissioner that it is
13unbiased, as defined by the commissioner by rule. An organization certified under
14this paragraph must be recertified on a biennial basis to continue to provide
15independent review services under this section.
AB518,12,2016 (b) An organization applying for certification or recertification as an
17independent review organization shall pay the applicable fee under s. 601.31 (1) (Lp)
18or (Lr). Every organization certified or recertified as an independent review
19organization shall file a report with the commissioner in accordance with rules
20promulgated under sub. (5) (a) 4.
AB518,12,2421 (c) The commissioner may examine, audit or accept an audit of the books and
22records of an independent review organization as provided for examination of
23licensees and permittees under s. 601.43 (1), (3), (4) and (5), to be conducted as
24provided in s. 601.44, and with costs to be paid as provided in s. 601.45.
AB518,13,9
1(d) The commissioner may revoke, suspend or limit in whole or in part the
2certification of an independent review organization, or may refuse to recertify an
3independent review organization, if the commissioner finds that the independent
4review organization is unqualified or has violated an insurance statute or rule or a
5valid order of the commissioner under s. 601.41 (4), or if the independent review
6organization's methods or practices in the conduct of its business endanger, or its
7financial resources are inadequate to safeguard, the legitimate interests of
8consumers and the public. The commissioner may summarily suspend an
9independent review organization's certification under s. 227.51 (3).
AB518,13,12 10(5) Rules; report; adjustments. (a) The commissioner shall promulgate rules
11for the independent review required under this section. The rules shall include at
12least all of the following:
AB518,13,1413 1. The application procedures for certification and recertification as an
14independent review organization.
AB518,13,1715 2. The standards that the commissioner will use for certifying and recertifying
16organizations as independent review organizations, including standards for
17determining whether an independent review organization is unbiased.
AB518,13,1918 3. Procedures and processes, in addition to those in sub. (3), that independent
19review organizations must follow.
AB518,13,2120 4. What must be included in the report required under sub. (4) and the
21frequency with which the report must be filed with the commissioner.
AB518,13,2322 5. Standards for the practices and conduct of independent review
23organizations.
AB518,13,2524 6. Standards, in addition to those in sub. (6), addressing conflicts of interest by
25independent review organizations.
AB518,14,2
17. Standards for contracts between insurers and independent review
2organizations.
AB518,14,63 (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.
AB518,14,97 (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.
AB518,14,11 10(6) Conflict of interest standards. (a) An independent review organization
11may not be affiliated with any of the following:
AB518,14,1212 1. A health benefit plan.
AB518,14,1413 2. A national, state or local trade association of health benefit plans, or an
14affiliate of any such association.
AB518,14,1615 3. A national, state or local trade association of health care providers, or an
16affiliate of any such association.
AB518,14,2017 (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:
AB518,14,2221 1. The insurer that issued the health benefit plan that is the subject of the
22independent review.
AB518,14,2423 2. Any officer, director or management employe of the insurer that issued the
24health benefit plan that is the subject of the independent review.
AB518,15,3
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.
AB518,15,54 4. The facility at which the health care service or treatment that is the subject
5of the independent review was or would be provided.
AB518,15,76 5. The developer or manufacturer of the principal procedure, equipment, drug
7or device that is the subject of the independent review.
AB518,15,88 6. The insured or his or her authorized representative.
AB518,15,11 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:
AB518,15,1412 (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 actual clinical experience.
AB518,15,2015 (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.
AB518,15,2221 (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.
AB518,15,2523 (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.
AB518,16,4
1(7) Immunity. (a) A certified independent review organization and a clinical
2peer reviewer who conducts reviews on behalf of a certified independent review
3organization shall not be liable in damages to any person for any opinion rendered
4during or at the completion of an independent review.
AB518,16,85 (b) A health benefit plan that is the subject of an independent review and the
6insurer that issued the health benefit plan shall not be liable in damages to any
7person for complying with any decision rendered by a certified independent review
8organization during or at the completion of an independent review.
AB518,16,15 9(8) Notice of sufficient independent review organizations. The
10commissioner shall make a determination that a sufficient number of independent
11review organizations have been certified under sub. (4) to effectively provide the
12independent reviews required under this section and shall publish a notice in the
13Wisconsin Administrative Register that states a date that is 6 months after the
14commissioner makes that determination. The date stated in the notice shall be the
15date on which the independent review procedure under this section begins operating.
AB518,17,2 16(9) Applicability. The independent review required under this section shall be
17available to an insured who receives notice of the disposition of his or her grievance
18under s. 632.83 (3) (d) on or after the first day of the 7th month beginning after the
19effective date of this subsection .... [revisor inserts date]. Notwithstanding sub. (2)
20(c), an insured who receives notice of the disposition of his or her grievance under s.
21632.83 (3) (d) on or after the first day of the 7th month beginning after the effective
22date of this subsection .... [revisor inserts date], but before the date stated in the
23notice published by the commissioner in the Wisconsin Administrative Register
24under sub. (8) .... [revisor inserts date], must request an independent review no later

1than 4 months after the date stated in the notice published by the commissioner in
2the Wisconsin Administrative Register under sub. (8) .... [revisor inserts date].
AB518, s. 20 3Section 20 . Nonstatutory provisions.
AB518,17,44 (1) Rules regarding independent review.
AB518,17,85 (a) The commissioner of insurance shall submit in proposed form the rules
6required under section 632.835 (5) (a) of the statutes, as created by this act, to the
7legislative council staff under section 227.15 (1) of the statutes no later than the first
8day of the 7th month beginning after the effective date of this paragraph.
AB518,17,189 (b) Using the procedure under section 227.24 of the statutes, the commissioner
10of insurance shall promulgate rules required under section 632.835 (5) (a) of the
11statutes, as created by this act, for the period before the effective date of the
12permanent rules promulgated under section 632.835 (5) (a) of the statutes, as created
13by this act, but not to exceed the period authorized under section 227.24 (1) (c) and
14(2) of the statutes. Notwithstanding section 227.24 (1) (a), (2) (b) and (3) of the
15statutes, the commissioner is not required to provide evidence that promulgating a
16rule under this paragraph as an emergency rule is necessary for the preservation of
17the public peace, health, safety or welfare and is not required to provide a finding of
18emergency for a rule promulgated under this paragraph.
AB518, s. 21 19Section 21. Effective dates. This act takes effect on the day after publication,
20except as follows:
AB518,17,2321 (1) The treatment of sections 609.15 (1) (intro.), (a), (b) and (c) and (2) (intro.),
22(a), (b), (c), (d) and (e) and 632.83 of the statutes takes effect on the first day of the
237th month beginning after publication.
AB518,18,224 (2) The treatment of section 632.835 (2), (3), (3m) and (5) (b) and (c) of the
25statutes takes effect on the date stated in the notice published by the commissioner

1of insurance in the Wisconsin Administrative Register under section 632.835 (8) of
2the statutes, as created by this act.
AB518,18,33 (End)
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