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)1.1. A proposed treatment has been reviewed.

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)(c)(c) “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.

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(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 website, 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 website, 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: