632.835(5)(a)(a) The commissioner shall promulgate rules for the independent review required under this section. The rules shall include at least all of the following:
632.835(5)(a)1.
1. The application procedures for certification and recertification as an independent review organization.
632.835(5)(a)2.
2. The standards that the commissioner will use for certifying and recertifying organizations as independent review organizations, including standards for determining whether an independent review organization is unbiased.
632.835(5)(a)3.
3. Procedures and processes, in addition to those in
sub. (3), that independent review organizations must follow.
632.835(5)(a)4.
4. What must be included in the report required under
sub. (4) and the frequency with which the report must be filed with the commissioner.
632.835(5)(a)5.
5. Standards for the practices and conduct of independent review organizations.
632.835(5)(a)6.
6. Standards, in addition to those in
sub. (6), addressing conflicts of interest by independent review organizations.
632.835(5)(b)
(b) The commissioner shall annually submit a report to the legislature under
s. 13.172 (2) that specifies the number of independent reviews requested under this section in the preceding year, the insurers and health benefit plans involved in the independent reviews and the dispositions of the independent reviews.
632.835(5)(c)
(c) To reflect changes in the consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor, the commissioner shall at least annually adjust the amounts specified in
sub. (1) (a) 4. and
(b) 4.
632.835(6)(a)(a) An independent review organization may not be affiliated with any of the following:
632.835(6)(a)2.
2. A national, state or local trade association of health benefit plans, or an affiliate of any such association.
632.835(6)(a)3.
3. A national, state or local trade association of health care providers, or an affiliate of any such association.
632.835(6)(b)
(b) An independent review organization appointed to conduct an independent review and a clinical peer reviewer assigned by an independent review organization to conduct an independent review may not have a material professional, familial or financial interest with any of the following:
632.835(6)(b)1.
1. The insurer that issued the health benefit plan that is the subject of the independent review.
632.835(6)(b)2.
2. Any officer, director or management employee of the insurer that issued the health benefit plan that is the subject of the independent review.
632.835(6)(b)3.
3. The health care provider that recommended or provided the health care service or treatment that is the subject of the independent review, or the health care provider's medical group or independent practice association.
632.835(6)(b)4.
4. The facility at which the health care service or treatment that is the subject of the independent review was or would be provided.
632.835(6)(b)5.
5. The developer or manufacturer of the principal procedure, equipment, drug or device that is the subject of the independent review.
632.835(6m)
(6m) Qualifications of clinical peer reviewers. A clinical peer reviewer who conducts a review on behalf of a certified independent review organization must satisfy all of the following requirements:
632.835(6m)(a)
(a) Be a health care provider who is expert in treating the medical condition that is the subject of the review and who is knowledgeable about the treatment that is the subject of the review through current, actual clinical experience.
632.835(6m)(b)
(b) Hold a credential, as defined in
s. 440.01 (2) (a), that is not limited or restricted; or hold a license, certificate, registration or permit that authorizes or qualifies the health care provider to perform acts substantially the same as those acts authorized by a credential, as defined in
s. 440.01 (2) (a), that was issued by a governmental authority in a jurisdiction outside this state and that is not limited or restricted.
632.835(6m)(c)
(c) If a physician, hold a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the review.
632.835(6m)(d)
(d) Have no history of disciplinary sanctions, including loss of staff privileges but excluding temporary suspension of staff privileges due to incomplete records, taken or pending by the medical examining board or another regulatory body or by any hospital or government.
632.835(7)(a)(a) A certified independent review organization is immune from any civil or criminal liability that may result because of an independent review determination made under this section. An employee, agent or contractor of a certified independent review organization is immune from civil liability and criminal prosecution for any act or omission done in good faith within the scope of his or her powers and duties under this section.
632.835(7)(b)
(b) A health benefit plan that is the subject of an independent review and the insurer that issued the health benefit plan shall not be liable to any person for damages attributable to the insurer's or plan's actions taken in compliance with any decision rendered by a certified independent review organization.
632.835(8)
(8) Notice of sufficient independent review organizations. The commissioner shall make a determination that at least one independent review organization has been certified under
sub. (4) that is able to effectively provide the independent reviews required under this section and shall publish a notice in the Wisconsin Administrative Register that states a date that is 2 months after the commissioner makes that determination. The date stated in the notice shall be the date on which the independent review procedure under this section begins operating.
632.835(9)
(9) Applicability. The independent review required under this section shall be available to an insured who receives notice of the disposition of his or her grievance under
s. 632.83 (3) (d) on or after December 1, 2000. Notwithstanding
sub. (2) (c), an insured who receives notice of the disposition of his or her grievance under
s. 632.83 (3) (d) on or after December 1, 2000, but before June 15, 2002, must request an independent review no later than 4 months after June 15, 2002.
632.835 History
History: 1999 a. 155;
2001 a. 65.
632.835 Cross-reference
Cross Reference: See also ch.
Ins 18, Wis. adm. code.
632.84
632.84
Benefit appeals under certain policies. 632.84(1)(b)
(b) "Nursing home insurance policy" means an individual or group insurance policy which provides coverage primarily for confinement or care in a nursing home.
632.84(2)(a)(a) Except as provided in
sub. (3), an insurer offering a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy shall establish an internal procedure by which the policyholder or the certificate holder or a representative of the policyholder or the certificate holder may appeal the denial of any benefits under the medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy. The procedure established under this paragraph shall include all of the following:
632.84(2)(a)1.
1. The opportunity for the policyholder or certificate holder or a representative of the policyholder or certificate holder to submit a written request, which may be in any form and which may include supporting material, for review by the insurer of the denial of any benefits under the policy.
632.84(2)(a)2.
2. Within 30 days after receiving the request under
subd. 1., disposition of the review and notification to the person submitting the request of the results of the review.
632.84(2)(b)
(b) An insurer shall describe the procedure established under
par. (a) in every policy, group certificate and outline of coverage issued in connection with a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy.
632.84(2)(c)
(c) If an insurer denies any benefits under a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy, the insurer shall, at the time the insurer gives notice of the denial of any benefits, provide the policyholder and certificate holder with a written description of the appeal process established under
par. (a).
632.84(2)(d)
(d) An insurer offering a medicare supplement policy, medicare replacement policy, nursing home insurance policy or long-term care insurance policy shall annually report to the commissioner a summary of all appeals filed under this section and the disposition of those appeals.
632.84(3)
(3) Exceptions. This section does not apply to a health maintenance organization, limited service health organization or preferred provider plan, as defined in
s. 609.01.
632.84 History
History: 1987 a. 156,
403;
1989 a. 31.
632.85
632.85
Coverage without prior authorization for treatment of an emergency medical condition. 632.85(1)(a)
(a) "Emergency medical condition" means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any of the following:
632.85(1)(a)1.
1. Serious jeopardy to the person's health or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child.
632.85(1)(a)2.
2. Serious impairment to the person's bodily functions.
632.85(1)(a)3.
3. Serious dysfunction of one or more of the person's body organs or parts.
632.85(1)(c)
(c) "Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.
632.85(2)
(2) If a health care plan or a self-insured health plan provides coverage of any emergency medical services, the health care plan or self-insured health plan shall provide coverage of emergency medical services that are provided in a hospital emergency facility and that are needed to evaluate or stabilize, as defined in section 1867 of the federal Social Security Act, an emergency medical condition.
632.85(3)
(3) A health care plan or a self-insured health plan that is required to provide the coverage under
sub. (2) may not require prior authorization for the provision or coverage of the emergency medical services specified in
sub. (2).
632.85 History
History: 1997 a. 155.
632.853
632.853
Coverage of drugs and devices. A health care plan, as defined in
s. 628.36 (2) (a) 1., or a self-insured health plan, as defined in
s. 632.85 (1) (c), that provides coverage of only certain specified prescription drugs or devices shall develop a process through which a physician may present medical evidence to obtain an individual patient exception for coverage of a prescription drug or device not routinely covered by the plan. The process shall include timelines for both urgent and nonurgent review.
632.853 History
History: 1997 a. 237.
632.855
632.855
Requirements if experimental treatment limited. 632.855(2)
(2) Disclosure of limitations. Subject to
s. 632.87 (6), a health care plan or a self-insured health plan that limits coverage of experimental treatment shall define the limitation and disclose the limits in any agreement, policy or certificate of coverage. This disclosure shall include the following information:
632.855(2)(a)
(a) Who is authorized to make a determination on the limitation.
632.855(2)(b)
(b) The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental.
632.855(3)(am)(am) A health care plan or a self-insured health plan that receives a request for prior authorization of an experimental procedure that includes all of the required information upon which to make a decision shall, within 5 working days after receiving the request, issue a coverage decision. If the health care plan or self-insured health plan denies coverage of an experimental treatment, procedure, drug or device for an insured who has a terminal condition or illness, the health care plan or self-insured health plan shall, as part of its coverage decision, provide the insured with a denial letter that includes all of the following:
632.855(3)(am)1.
1. A statement setting forth the specific medical and scientific reasons for denying coverage.
632.855(3)(am)2.
2. Notice of the insured's right to appeal and a description of the appeal procedure.
632.855(3)(bm)
(bm) A health care plan or a self-insured health plan may not deny coverage under
par. (am) of an experimental treatment, procedure, drug, or device for an insured if the denial violates
s. 632.87 (6).
632.855 History
History: 1997 a. 237;
2005 a. 194.
632.86
632.86
Restrictions on pharmaceutical services. 632.86(1)(a)
(a) "Disability insurance policy" has the meaning given in
s. 632.895 (1) (a), except that the term does not include coverage under a health maintenance organization, as defined in
s. 609.01 (2), a limited service health organization, as defined in
s. 609.01 (3), a preferred provider plan, as defined in
s. 609.01 (4), or a sickness care plan operated by a cooperative association organized under
ss. 185.981 to
185.985.
632.86(1)(b)
(b) "Pharmaceutical mail order plan" means a plan under which prescribed drugs or devices are dispensed through the mail.
632.86(2)
(2) No group or blanket disability insurance policy that provides coverage of prescribed drugs or devices through a pharmaceutical mail order plan may do any of the following:
632.86(2)(a)
(a) Exclude coverage, expressly or by implication, of any prescribed drug or device provided by a pharmacist or pharmacy selected by a covered individual if the pharmacist or pharmacy provides or agrees to provide prescribed drugs or devices under the terms of the policy and at the same cost to the insurer issuing the policy as a pharmaceutical mail order plan.
632.86(2)(b)
(b) Contain coverage, deductible or copayment provisions for prescribed drugs or devices provided by a pharmacist or pharmacy selected by a covered individual that are different from the coverage, deductible or copayment provisions for prescribed drugs or devices provided by a pharmaceutical mail order plan.
632.86 History
History: 1991 a. 70.
632.87
632.87
Restrictions on health care services. 632.87(1)
(1) No insurer may refuse to provide or pay for benefits for health care services provided by a licensed health care professional on the ground that the services were not rendered by a physician as defined in
s. 990.01 (28), unless the contract clearly excludes services by such practitioners, but no contract or plan may exclude services in violation of
sub. (2),
(2m),
(3),
(4),
(5), or
(6).
632.87(2)
(2) No insurer may, under a contract or plan covering vision care services or procedures, refuse to provide coverage for vision care services or procedures provided by an optometrist licensed under
ch. 449 within the scope of the practice of optometry, as defined in
s. 449.01 (1), if the contract or plan includes coverage for the same services or procedures when provided by another health care provider.
632.87(2m)(a)(a) No health maintenance organization or preferred provider plan that provides vision care services or procedures within the scope of the practice of optometry, as defined in
s. 449.01 (1), may do any of the following:
632.87(2m)(a)1.
1. Fail to provide to persons covered by the health maintenance organization or preferred provider plan, at the time of enrollment and annually thereafter, a listing of then participating vision care providers, including participating optometrists, setting forth the names of the vision care providers in alphabetical order by last name and their respective business addresses and telephone numbers, with the listing of participating vision care providers to be incorporated in any listing of all participating health care providers that includes the same information regarding all providers, if such listing is provided at the time of enrollment and annually thereafter, or with the listing of participating vision care providers otherwise to be provided separately.
632.87(2m)(a)2.
2. Fail to provide to persons covered by the health maintenance organization or preferred provider plan, at the time vision care services or procedures are needed, the opportunity to choose optometrists from the listing under
subd. 1. from whom the persons may obtain covered vision care services and procedures within the scope of the practice of optometry, as defined in
s. 449.01 (1).
