Ins 18.06Ins 18.06 Reporting requirements. An insurer offering a health benefit plan shall comply with all of the following requirements:

Ins 18.06(1)(1) Each record of each complaint and grievance submitted to the insurer shall be kept and retained for a period of at least 3 years. These records shall be maintained at the insurer’s home or principal office and shall be available for review during examinations by or on request of the commissioner or office.

Ins 18.06(2)(2) Submit a grievance experience report required by s. 632.83 (2) (c), Stats., to the commissioner by March 1 of each year. The report shall provide information on all grievances received during the previous calendar year. The report shall be in a form prescribed by the commissioner and, at a minimum, shall classify grievances into the following categories:

Ins 18.06(2)(a)(a) Plan administration including plan marketing, policyholder service, billing, underwriting and similar administrative functions.

Ins 18.06(2)(b)(b) Benefit services including denial of a benefit, denial of experimental treatment, quality of care, refusal to refer insureds or to provide requested services.

Ins 18.06 NoteNote: A copy of the grievance experience report form OCI26-007, required under par. (2), may be obtained from the Office of the Commissioner of Insurance, P. O. Box 7873, Madison WI 53707-7873.

Ins 18.10Ins 18.10 Definitions. In addition to the definitions in s. 632.835 (1), Stats., in this subchapter:

Ins 18.10(1)(1) “Adverse determination” has the meaning as defined in s. 632.835 (1) (a), Stats. This includes the denial of a request for a referral for out-of-network services when the insured requests health care services from a provider that does not participate in the insurer’s provider network because the clinical expertise of the provider may be medically necessary for treatment of the insured’s medical condition and that expertise is not available in the insurer’s provider network.

Ins 18.10(2)(2) “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:

Ins 18.10(2)(b)(b) Based on the information provided, the treatment under par. (a) is determined to be experimental under the terms of the health benefit plan.

Ins 18.10(2)(c)(c) Based on the information provided, the insurer that issued the health benefit plan denied the treatment under par. (a) or payment for the treatment under par. (a).

Ins 18.10(2)(d)(d) Pursuant to s. 632.835 (5) (c), Stats., the cost or expected cost of the denied treatment or payment exceeds, or will exceed during the course of the treatment, the amount published in accordance with s. Ins 18.105.

Ins 18.10(3)(3) “Health benefit plan” has the meaning provided in s. 632.835 (1) (c), Stats., and includes Medicare supplement and replacement plans as defined in s. 600.03 (28p) and (28r), Stats., and s. Ins 3.39 (3) (v) and (w). Health benefit plan includes Medicare cost and select plans but does not include Medicare Advantage plans.

Ins 18.10(4)(4) “Medical or scientific evidence” means information from any of the following sources:

Ins 18.10(4)(a)(a) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.

Ins 18.10(4)(b)(b) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health’s Library of Medicine for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline and MEDLARS database Health Services Technology Assessment Research (HSTAR).

Ins 18.10(4)(c)(c) Medical journals recognized by the Secretary of Health and Human Services under 42 USC1320c et. seq. of the federal Social Security Act.

Ins 18.10(4)(d)(d) Any of the following standard reference compendia most current edition in publication at the time of the dispute:

Ins 18.10(4)(e)(e) Findings, studies or research conducted by, or under the auspices of, federal governmental agencies and nationally recognized federal research institutes, including: