632.798(2)(d)
(d) Before providing the information requested under
par. (a), the insurer or self-insured health plan may require the insured to provide in writing any of the following information:
632.798(2)(d)1.
1. The name of the health care provider providing the service.
632.798(2)(d)4.
4. The health care provider's estimate of the charge for the service.
632.798(2)(d)5.
5. The codes for the service under the Current Procedural Terminology of the American Medical Association or under the Current Dental Terminology of the American Dental Association.
632.798(2)(e)
(e) The requirement to provide the information requested under
par. (a) does not apply if the health care provider providing the health care service is any of the following:
632.798(2)(e)1.
1. A health care provider that practices individually or in association with not more than 2 other individual health care providers.
632.798(2)(e)2.
2. A health care provider that is an association of 3 or fewer individual health care providers.
632.798 History
History: 2009 a. 146.
632.80
632.80
Restrictions on medical payments insurance. The provisions of this subchapter do not apply to medical payments insurance when it is a part of or supplemental to liability, steam boiler, elevator, automobile or other insurance covering loss of or damage to property, provided the loss, damage or expense arises out of a hazard directly related to such other insurance.
632.80 History
History: 1975 c. 375.
632.81
632.81
Minimum standards for certain disability policies. The commissioner may by rule establish minimum standards for benefits, claims payments, marketing practices, compensation arrangements and reporting practices for medicare supplement policies, medicare replacement policies and long-term care insurance policies. The commissioner may by rule exempt from the minimum standards certain types of coverage, if the commissioner finds the exemption is not adverse to the interests of policyholders and certificate holders.
632.81 Cross-reference
Cross-reference: See also ss.
Ins 3.39,
3.455, and
3.46, Wis. adm. code.
632.82
632.82
Renewability of long-term care insurance policies. Notwithstanding
s. 631.36 (2) to
(5), the commissioner shall, by rule, require long-term care insurance policies that are issued on an individual basis to include a provision restricting the insurer's ability to terminate or alter the long-term care insurance policy except for nonpayment of premium. The rule may specify exceptions to the restriction, including exceptions that allow insurers to do any of the following:
632.82(1)
(1) Change the rates charged on a long-term care insurance policy if the rate change is made on a class basis.
632.82(2)
(2) Refuse to renew a long-term care insurance policy if conditions specified in the rule are satisfied. The conditions shall, at a minimum, require all of the following:
632.82(2)(a)
(a) That the nonrenewal be on other than an individual basis.
632.82(2)(b)
(b) That the insurer demonstrate to the commissioner that renewal will affect the insurer's solvency or loss experience as specified in the rule.
632.82 History
History: 1989 a. 31.
632.825
632.825
Midterm termination of long-term care insurance policy by insured. 632.825(1)(a)(a) No insurer that provides coverage under a long-term care insurance policy may prohibit the insured under the policy from canceling the policy before the expiration of the agreed term.
632.825(1)(b)
(b) If an insured under a long-term care insurance policy cancels the policy before the expiration of the agreed term, the insurer shall issue a prorated premium refund to the insured.
632.825(1)(c)
(c) If an insured under a long-term care insurance policy dies during the term of the policy, the insurer shall issue a prorated premium refund to the insured's estate.
632.825(2)
(2) Policy provision. Every long-term care insurance policy shall contain a provision that apprises the insured of the insured's right to cancel and the insurer's premium refund responsibilities under
sub. (1).
632.825 History
History: 1993 a. 207.
632.825 Cross-reference
Cross-reference: See also ss.
Ins 3.455 and
3.46, Wis. adm. code.
632.83
632.83
Internal grievance procedure. 632.83(1)
(1) In this section, "health benefit plan" has the meaning given in
s. 632.745 (11), except that "health benefit plan" includes the coverage specified in
s. 632.745 (11) (b) 10. and includes a policy, certificate or contract under
s. 632.745 (11) (b) 9. that provides only limited-scope dental or vision benefits.
632.83(2)
(2) Every insurer that issues a health benefit plan shall do all of the following:
632.83(2)(a)
(a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with
sub. (3) for the resolution of insureds' grievances with the health benefit plan.
632.83(2)(b)
(b) Provide insureds with complete and understandable information describing the internal grievance procedure under
par. (a).
632.83(2)(c)
(c) Submit an annual report to the commissioner describing the internal grievance procedure under
par. (a) and summarizing the experience under the procedure for the year.
632.83(3)
(3) The internal grievance procedure established under
sub. (2) (a) shall include all of the following elements:
632.83(3)(a)
(a) The opportunity for an insured to submit a written grievance in any form.
632.83(3)(b)
(b) Establishment of a grievance panel for the investigation of each grievance submitted under
par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one insured other than the grievant, if an insured is available to serve on the grievance panel.
632.83(3)(c)
(c) Prompt investigation of each grievance submitted under
par. (a).
632.83(3)(d)
(d) Notification to each grievant of the disposition of his or her grievance and of any corrective action taken on the grievance.
632.83(3)(e)
(e) Retention of records pertaining to each grievance for at least 3 years after the date of notification under
par. (d).
632.83 History
History: 1999 a. 155 ss.
8 to
17; Stats. 1999 s. 632.83.
632.835
632.835
Independent review of coverage denial determinations. 632.835(1)(a)
(a) "Adverse determination" means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:
632.835(1)(a)1.
1. An admission to a health care facility, the availability of care, the continued stay or other treatment that is a covered benefit has been reviewed.
632.835(1)(a)2.
2. Based on the information provided, the treatment under
subd. 1. does not meet the health benefit plan's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness.
632.835(1)(a)3.
3. Based on the information provided, the insurer that issued the health benefit plan reduced, denied or terminated the treatment under
subd. 1. or payment for the treatment under
subd. 1.
632.835(1)(a)4.
4. Subject to
sub. (5) (c), the amount of the reduction or the cost or expected cost of the denied or terminated treatment or payment exceeds, or will exceed during the course of the treatment, $250.
632.835(1)(ag)
(ag) "Coverage denial determination" means an adverse determination, an experimental treatment determination, a preexisting condition exclusion denial determination, or the rescission of a policy or certificate.
632.835(1)(b)
(b) "Experimental treatment determination" means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:
632.835(1)(b)2.
2. Based on the information provided, the treatment under
subd. 1. is determined to be experimental under the terms of the health benefit plan.
632.835(1)(b)3.
3. Based on the information provided, the insurer that issued the health benefit plan denied the treatment under
subd. 1. or payment for the treatment under
subd. 1.
632.835(1)(b)4.
4. Subject to
sub. (5) (c), the cost or expected cost of the denied treatment or payment exceeds, or will exceed during the course of the treatment, $250.
632.835(1)(cm)
(cm) "Preexisting condition exclusion denial determination" means a determination by or on behalf of an insurer that issues a health benefit plan denying or terminating treatment or payment for treatment on the basis of a preexisting condition exclusion, as defined in
s. 632.745 (23).
632.835(1)(d)
(d) "Treatment" means a medical service, diagnosis, procedure, therapy, drug or device.
632.835(2)
(2) Review requirements; who may conduct. 632.835(2)(a)(a) Every insurer that issues a health benefit plan shall establish an independent review procedure whereby an insured under the health benefit plan, or his or her authorized representative, may request and obtain an independent review of a coverage denial determination made with respect to the insured.
632.835(2)(b)
(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.
632.835(2)(bg)
(bg) Notwithstanding
par. (b), an insurer is not required to provide the notice under
par. (b) to an insured until the insurer sends notice of the disposition of the internal grievance if all of the following apply:
632.835(2)(bg)1.
1. The health benefit plan issued by the insurer contains a description of the independent review procedure under this section, including an explanation of the insured's rights under
par. (d), how to request the review, the time within which the review must be requested, and how to obtain a current listing of independent review organizations certified under
sub. (4).
632.835(2)(bg)2.
2. The insurer includes on its explanation of benefits form a statement that the insured may have a right to an independent review after the internal grievance process and that an insured may be entitled to expedited independent review with respect to an urgent matter. The statement shall also include a reference to the section of the policy or certificate that contains the description of the independent review procedure as required under
subd. 1. The statement shall provide a toll-free telephone number and Web site, if appropriate, where consumers may obtain additional information regarding internal grievance and independent review processes.
632.835(2)(bg)3.
3. For any coverage denial determination for which an explanation of benefits is not provided to the insured, the insurer provides a notice that the insured may have a right to an independent review after the internal grievance process and that an insured may be entitled to expedited, independent review with respect to an urgent matter. The notice shall also include a reference to the section of the policy or certificate that contains the description of the independent review procedure as required under
subd. 1. The notice shall provide a toll-free telephone number and Web site, if appropriate, where consumers may obtain additional information regarding internal grievance and independent review processes.
632.835(2)(c)
(c) Except as provided in
par. (d), an insured must exhaust the internal grievance procedure under
s. 632.83 before the insured may request an independent review under this section. Except as provided in
sub. (9) (a), an insured who uses the internal grievance procedure must request an independent review as provided in
sub. (3) (a) within 4 months after the insured receives notice of the disposition of his or her grievance under
s. 632.83 (3) (d).
632.835(2)(d)
(d) An insured is not required to exhaust the internal grievance procedure under
s. 632.83 before requesting an independent review if any of the following apply:
632.835(2)(d)1.
1. The insured and the insurer agree that the matter may proceed directly to independent review under
sub. (3).
632.835(2)(d)2.
2. Along with the notice to the insurer of the request for independent review 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.
632.835(2)(e)
(e) Nothing in this section affects an insured's right to commence a civil proceeding relating to a coverage denial determination.
632.835(3)(a)(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 insurer that made or on whose behalf was made the coverage denial determination. The insurer shall immediately notify the commissioner and the independent review organization selected by the insured of the request for independent review. For each independent review in which it is involved, an insurer shall pay a fee to the independent review organization.
632.835(3)(b)
(b) Within 5 business days after receiving written notice of a request for independent review under
par. (a), the insurer shall submit to the independent review organization copies of all of the following:
632.835(3)(b)1.
1. Any information submitted to the insurer by the insured in support of the insured's position in the internal grievance under
s. 632.83.
632.835(3)(b)2.
2. The contract provisions or evidence of coverage of the insured's health benefit plan.
632.835(3)(b)3.
3. Any other relevant documents or information used by the insurer in the internal grievance determination under
s. 632.83.
632.835(3)(c)
(c) Within 5 business days after receiving the information under
par. (b), the independent review organization shall request any additional information that it requires for the review from the insured or the insurer. Within 5 business days after receiving a request for additional information, the insured or the insurer shall submit the information or an explanation of why the information is not being submitted.
632.835(3)(d)
(d) An independent review under this section may not include appearances by the insured or his or her authorized representative, any person representing the health benefit plan or any witness on behalf of either the insured or the insurer.
632.835(3)(e)
(e) In addition to the information under
pars. (b) and
(c), the independent review organization may accept for consideration any typed or printed, verifiable medical or scientific evidence that the independent review organization determines is relevant, regardless of whether the evidence has been submitted for consideration at any time previously. The insurer and the insured shall submit to the other party to the independent review any information submitted to the independent review organization under this paragraph and
pars. (b) and
(c). If, on the basis of any additional information, the insurer reconsiders the insured's grievance and determines that the treatment that was the subject of the grievance should be covered, or that the policy or certificate that was rescinded should be reinstated, the independent review is terminated.
632.835(3)(f)1.1. 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. Except as provided in
subd. 2., a decision of an independent review organization is binding on the insured and the insurer.
632.835(3)(f)2.
2. A decision of an independent review organization regarding a preexisting condition exclusion denial determination or a rescission is not binding on the insured.
632.835(3)(g)
(g) 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 procedure outlined in
pars. (b) to
(f) shall be followed with the following differences:
632.835(3)(g)1.
1. The insurer shall submit the information under
par. (b) within one day after receiving the notice of the request for independent review under
par. (a).
632.835(3)(g)2.
2. The independent review organization shall request any additional information under
par. (c) within 2 business days after receiving the information under
par. (b).
632.835(3)(g)3.
3. The insured or insurer shall, within 2 days after receiving a request under
par. (c), submit any information requested or an explanation of why the information is not being submitted.
632.835(3)(g)4.
4. The independent review organization shall make its decision under
par. (f) within 72 hours after the expiration of the time limits under this paragraph that apply in the matter.
632.835(3m)(a)(a) A decision of an independent review organization regarding an adverse determination or a preexisting condition exclusion denial determination must be consistent with the terms of the health benefit plan under which the adverse determination or preexisting condition exclusion denial determination was made.
