Chapter 632

632.835(3m) (3m) Standards for decisions.

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.

632.835(3m)(b) (b) 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 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:

632.835(3m)(b)1. 1. The treatment has been approved by the federal food and drug administration, if the treatment is subject to the approval of the federal food and drug administration.

632.835(3m)(b)2. 2. Medically and scientifically accepted evidence clearly demonstrates that the treatment meets all of the following criteria:

632.835(3m)(b)2.a. a. The treatment is proven safe.

632.835(3m)(b)2.b. b. The treatment can be expected to produce greater benefits than the standard treatment without posing a greater adverse risk to the insured.

632.835(3m)(b)2.c. c. The treatment meets the coverage terms of the health benefit plan and is not specifically excluded under the terms of the health benefit plan.

632.835(4) (4) Certification of independent review organizations.

632.835(4)(a) (a) The commissioner shall certify independent review organizations. An independent review organization must demonstrate to the satisfaction of the commissioner that it is unbiased, as defined by the commissioner by rule. An organization certified under this paragraph must be recertified on a biennial basis to continue to provide independent review services under this section.

632.835(4)(ag) (ag) An independent review organization shall have in operation a quality assurance mechanism to ensure the timeliness and quality of the independent reviews, the qualifications and independence of the clinical peer reviewers and the confidentiality of the medical records and review materials.

632.835(4)(ap) (ap) An independent review organization shall establish reasonable fees that it will charge for independent reviews and shall submit its fee schedule to the commissioner for a determination of reasonableness and for approval. An independent review organization may not change any fees approved by the commissioner more than once per year and shall submit any proposed fee changes to the commissioner for approval.

632.835(4)(b) (b) An organization applying for certification or recertification as an independent review organization shall pay the applicable fee under s. 601.31 (1) (Lp) or (Lr). Every organization certified or recertified as an independent review organization shall file a report with the commissioner in accordance with rules promulgated under sub. (5) (a) 4.

632.835(4)(c) (c) The commissioner may examine, audit or accept an audit of the books and records of an independent review organization as provided for examination of licensees and permittees under s. 601.43 (1), (3), (4) and (5), to be conducted as provided in s. 601.44, and with costs to be paid as provided in s. 601.45.

632.835(4)(d) (d) The commissioner may revoke, suspend or limit in whole or in part the certification of an independent review organization, or may refuse to recertify an independent review organization, if the commissioner finds that the independent review organization is unqualified or has violated an insurance statute or rule or a valid order of the commissioner under s. 601.41 (4), or if the independent review organization’s methods or practices in the conduct of its business endanger, or its financial resources are inadequate to safeguard, the legitimate interests of consumers and the public. The commissioner may summarily suspend an independent review organization’s certification under s. 227.51 (3).

632.835(4)(e) (e) The commissioner shall keep an up-to-date listing of certified independent review organizations and shall provide a copy of the listing to all of the following:

632.835(4)(e)1. 1. Every insurer that is subject to this section, at least quarterly.

632.835(4)(e)2. 2. Any person who requests a copy of the listing.

632.835(5) (5) Rules; report; adjustments.

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) (6) Conflict of interest standards.

632.835(6)(a) (a) An independent review organization may not be affiliated with any of the following:

632.835(6)(a)1. 1. A health benefit plan.

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(6)(b)6. 6. The insured or his or her authorized representative.

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) (7) Immunity.

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 regarding an adverse determination or an experimental treatment determination rendered by a certified independent review organization.

632.835(8) (8) Notice of sufficient independent review organizations.

632.835(8)(a) (a) Adverse and experimental treatment determinations. 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 for adverse determinations and experimental treatment determinations 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 with respect to adverse determinations and experimental treatment determinations.

632.835(8)(b) (b) Preexisting condition exclusion denials and rescissions. 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 for preexisting condition exclusion denial determinations and rescissions 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 with respect to preexisting condition exclusion denial determinations and rescissions.

632.835(9) (9) Applicability.

632.835(9)(a) (a) Adverse and experimental treatment determinations. The independent review required under this section with respect to an adverse determination or an experimental treatment determination 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, with respect to an adverse determination or an experimental treatment determination must request an independent review no later than 4 months after June 15, 2002.

632.835(9)(b) (b) Preexisting condition exclusion denials and rescissions. The independent review required under this section with respect to a preexisting condition exclusion denial determination or a rescission 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 the date stated in the notice published in the Wisconsin Administrative Register by the commissioner under sub. (8) (b).

632.835 History History: 1999 a. 155; 2001 a. 65; 2009 a. 28, 276; 2017 a. 365 s. 112.

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) (1) Definitions. In this section:

632.84(1)(a) (a) “Nursing home” has the meaning given in s. 50.01 (3).

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) (2) Review and appeal.

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.

632.84 Cross-reference Cross-reference: See also s. Ins 3.55, Wis. adm. code.

632.845 632.845 Prohibiting refusal to cover services because liability policy may cover.

632.845(1) (1) In this section, “health care plan” has the meaning given in s. 628.36 (2) (a) 1.

632.845(2) (2) An insurer that provides coverage under a health care plan may not refuse to cover health care services that are provided to an insured under the plan and for which there is coverage under the plan on the basis that there may be coverage for the services under a liability insurance policy.

632.845 History History: 2009 a. 28.

632.85 632.85 Coverage without prior authorization for treatment of an emergency medical condition.

632.85(1) (1) In this section:

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)(b) (b) “Health care plan” has the meaning given in s. 628.36 (2) (a) 1.

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(1) (1) Definitions. In this section: