AB696: Bill Text

AB696, s. 2 Section 2. 632.835 (1) (b) 2. of the statutes is amended to read:

AB696,3,5 632.835 (1) (b) 2. Based on the information provided, the treatment under subd. 1. is determined to be experimental or investigational under the terms of the health benefit plan.

AB696, s. 3 Section 3. 632.835 (1) (b) 4. of the statutes is repealed.

AB696, s. 4 Section 4. 632.835 (2) (b) of the statutes is amended to read:

AB696,3,15 632.835 (2) (b) If a coverage denial determination is made, the insurer involved in the determination shall provide notice to the insured of the insured's right to obtain the independent review required under this section, how to request the review, and the time within which the review must be requested. The notice shall include a current listing of independent review organizations certified under sub. (4). An independent review under this section may be conducted only by an independent review organization certified under sub. (4) and selected by the insured commissioner under sub. (3) (a).

AB696, s. 5 Section 5. 632.835 (2) (d) 2. of the statutes is amended to read:

AB696,4,4 632.835 (2) (d) 2. Along with the notice to the insurer of the request for After receiving notice of the independent review organization selected by the commissioner under sub. (3) (a), the insured submits to the independent review organization selected by the insured a request to bypass the internal grievance procedure under s. 632.83 and the independent review organization determines that the health condition of the insured is such that requiring the insured to use the internal grievance procedure before proceeding to independent review would jeopardize the life or health of the insured or the insured's ability to regain maximum function.

AB696, s. 6 Section 6. 632.835 (2) (d) 3. of the statutes is created to read:

AB696,4,8 632.835 (2) (d) 3. The insurer or another entity other than the insured does not meet all of the timeline requirements, if any, under the internal grievance procedure under s. 632.83.

AB696, s. 7 Section 7. 632.835 (3) (a) of the statutes is amended to read:

AB696,4,23 632.835 (3) (a) To request an independent review, an insured or his or her authorized representative shall provide timely written notice of the request for independent review, and of the independent review organization selected, to the commissioner and to the insurer that made or on whose behalf was made the coverage denial determination. The insurer shall immediately notify No more than 2 business days after receiving the notice of the request for independent review, the commissioner and the shall, on a random basis, select an independent review organization selected by the insured of the request for independent review certified under sub. (4) to conduct the independent review based on the subject of the review and other circumstances, including any conflict of interest concerns, and shall notify the independent review organization, the insured or his or her authorized representative, and the insurer of the independent review organization selected. For each independent review in which it is involved, an insurer shall pay a fee to the independent review organization.

AB696, s. 8 Section 8. 632.835 (3) (b) (intro.) of the statutes is amended to read:

AB696,5,4 632.835 (3) (b) (intro.) Within 5 business days after receiving written notice from the commissioner of a request for the independent review organization selected under par. (a), the insurer shall submit to the independent review organization copies of all of the following:

AB696, s. 9 Section 9. 632.835 (3) (dm) of the statutes is created to read:

AB696,5,8 632.835 (3) (dm) An independent review of an experimental treatment determination shall provide for all of the same protections that apply in an independent review of an adverse determination.

AB696, s. 10 Section 10. 632.835 (3) (f) 1. of the statutes is renumbered 632.835 (3) (f) 1. a. and amended to read:

AB696,5,17 632.835 (3) (f) 1. a. If the independent review is not terminated under par. (e), the independent review organization shall, within 30 business days after the expiration of all time limits that apply in the matter, make a decision on the basis of the documents and information submitted under this subsection. The decision shall be in writing, signed on behalf of the independent review organization and served by personal delivery or by mailing a copy to the insured or his or her authorized representative and to the insurer.

AB696,5,19 2. a. Except as provided in subd. 2. b., a decision of an independent review organization is binding on the insured and the insurer.

AB696, s. 11 Section 11. 632.835 (3) (f) 1. b. of the statutes is created to read:

AB696,5,25 632.835 (3) (f) 1. b. Notwithstanding the timelines specified in subd. 1. a. and pars. (b) and (c), in no case may the written decision under subd. 1. a. be served or mailed to the insured, or his or her authorized representative, or to the insurer more than 60 calendar days after the independent review organization received notice from the commissioner of its selection under par. (a).

AB696, s. 12 Section 12. 632.835 (3) (f) 2. of the statutes is renumbered 632.835 (3) (f) 2. b.

AB696, s. 13 Section 13. 632.835 (3) (g) of the statutes is repealed and recreated to read:

AB696,6,10 632.835 (3) (g) 1. If the independent review organization determines that the health condition of the insured is such that following the procedure outlined in pars. (b) to (f) would jeopardize the life or health of the insured or the insured's ability to regain maximum function, the independent review organization shall follow an expedited independent review process and notify the insured, or his or her authorized representative, and the insurer of its decision no more than 4 business days after receiving notice from the commissioner of its selection under par. (a).

AB696,6,13 2. If the notice of its decision under subd. 1. is not in writing, the independent review organization shall provide written confirmation of its decision within 48 hours after the date of the notice of the decision under subd. 1.

AB696, s. 14 Section 14. 632.835 (3m) (b) (intro.) of the statutes is amended to read:

AB696,6,20 632.835 (3m) (b) (intro.) A With respect to a decision of an independent review organization regarding an experimental treatment determination is limited to a determination of whether the proposed treatment is experimental. The, the independent review organization shall determine that the treatment is not experimental and find in favor of the insured only if the independent review organization finds all of the following:

AB696, s. 15 Section 15. 632.835 (5) (c) of the statutes is repealed.

AB696, s. 16 Section 16. Initial applicability.

AB696,6,24 (1) This act first applies to independent reviews that are requested by insureds under all of the following:

AB696,7,2 (a) Except as provided in paragraph (b), health benefit plans that are newly issued or renewed on the effective date of this paragraph.

AB696,7,5 (b) Health benefit plans covering employees who are affected by a collective bargaining agreement containing provisions inconsistent with this act that are newly issued or renewed on the earlier of the following:

AB696,7,6 1. The day on which the collective bargaining agreement expires.

AB696,7,8 2. The day on which the collective bargaining agreement is extended, modified, or renewed.

AB696, s. 17 Section 17. Effective date.

AB696,7,11 (1) This act takes effect on the first day of the 2nd month beginning after publication.

AB696,7,12 (End)