Ins 18.03(2)(c)1.b. b. Require contracted entities that subcontract for the provision of services, including subcontracts with health care providers, to incorporate within their contracts a requirement that the providers promptly respond to complaints and grievances filed with the insurer to facilitate resolution.

Ins 18.03(2)(c)1.c. c. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.

Ins 18.03(2)(c)1.d. d. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.

Ins 18.03(2)(c)2. 2. An insurer offering a health benefit plan that is a preferred provider plan as defined in s. 609.01 (4), Stats., shall do all of the following:

Ins 18.03(2)(c)2.a. a. Include in each contract between it and its providers, provider networks and within each agreement governing the administration of provider services, a provision that requires the contracting entity to promptly provide the insurer the information necessary to permit the insurer to respond to complaints or grievances described under subd. 2. c.

Ins 18.03(2)(c)2.b. b. Require contracted entities that subcontract for the provision of services, to incorporate within their contracts, including subcontracts with health care providers, a requirement that the subcontractor promptly provide the insurer with the information necessary to respond to complaints or grievances described under subd. 2. c.

Ins 18.03(2)(c)2.c. c. Include in its description of the grievance process required under sub. (1), a clear statement that an insured may submit to the insurer offering a health benefit plan a complaint or grievance relating to covered services provided by a participating health care provider.

Ins 18.03(2)(c)2.d. d. Process and respond to a complaint or grievance described under subd. 2. c.

Ins 18.03(2)(c)2.e. e. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.

Ins 18.03(2)(c)2.f. f. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.

Ins 18.03(2)(d) (d) If the insurer offering a health benefit plan is either a health maintenance organization as defined in s. 609.01 (2), Stats., or a limited service health organization as defined by s. 609.01 (3), Stats., and the insurer initiates disenrollment proceedings, the insurer shall additionally comply with s. Ins 9.39.

Ins 18.03(3) (3) Grievance procedure. The grievance procedure utilized by an insurer offering a health benefit plan shall include all of the following:

Ins 18.03(3)(a) (a) A method whereby the insured who filed the grievance, or the insured’s authorized representative, has the right to appear in person before the grievance panel to present written or oral information. The insurer shall permit the grievant to submit written questions to the person or persons responsible for making the determination that resulted in the denial, determination, or initiation of disenrollment unless the insurer permits the insured or insured’s authorized representative to meet with and question the decision maker or makers.

Ins 18.03(3)(b) (b) A written notification to the insured of the time and place of the grievance meeting at least 7 calendar days before the meeting.

Ins 18.03(3)(c) (c) Reasonable accommodations to allow the insured, or the insured’s authorized representative, to participate in the meeting.

Ins 18.03(3)(d) (d) The grievance panel shall comply with the requirements of s. 632.83 (3) (b), Stats., and shall not include the person who ultimately made the initial determination. If the panel consists of at least three persons, the panel may then include no more than one subordinate of the person who ultimately made the initial determination. The panel may, however, consult with the ultimate initial decision-maker.

Ins 18.03(3)(e) (e) The insured member of the panel shall not be an employee of the plan, to the extent possible.

Ins 18.03(3)(f) (f) Consultation with a licensed health care provider with expertise in the field relating to the grievance, if appropriate.

Ins 18.03(3)(g) (g) The panel’s written decision to the insured as described in s. 632.83 (3) (d), Stats., shall be signed by one voting member of the panel and include a written description of position titles of panel members involved in making the decision.

Ins 18.03(4) (4) Receipt of grievance acknowledgment. An insurer offering a health benefit plan shall, within 5 business days of receipt of a grievance, deliver or deposit in the mail a written acknowledgment to the insured or the insured’s authorized representative confirming receipt of the grievance.

Ins 18.03(5) (5) Authorization for release of information.

Ins 18.03(5)(a) (a) An insurer offering a health benefit plan may require a written expression of authorization for representation from a person acting as the insured’s authorized representative unless any of the following applies:

Ins 18.03(5)(a)1. 1. The person is authorized by law to act on behalf of the insured.

Ins 18.03(5)(a)2. 2. The insured is unable to give consent and the person is a spouse, family member or the treating provider.

Ins 18.03(5)(a)3. 3. The grievance is an expedited grievance and the person represents that the insured has verbally given authorization to represent the insured.

Ins 18.03(5)(b) (b) An insurer offering a health benefit plan shall process a grievance without requiring written authorization unless the insurer, in its acknowledgement to the person under sub. (4), clearly and prominently does all of the following:

Ins 18.03(5)(b)1. 1. Notifies the person that, unless an exception under par. (a) applies, the grievance will not be processed until the insurer receives a written authorization.

Ins 18.03(5)(b)2. 2. Requests written authorization from the person.

Ins 18.03(5)(b)3. 3. Provides the person with a form the insured may use to give written authorization. An insured may, but is not required to, use the insurer’s form to give written authorization.