Has your health plan refused to cover some treatment that you believe was medically necessary? All insurance companies offering health benefit plans in Wisconsin are required to have an internal grievance process to resolve any complaint you may have with the plan. If you are not satisfied with the outcome of your grievance, you now have the right to ask that your dispute be reviewed by an independent medical expert.

Recently, you may have received information from your health plan that explains your right to request an independent review of some of your health plan's decisions. Wisconsin's independent review program became available this year on June 15. This program allows you to have your dispute with your health plan reviewed by a health professional who has no connection to the health plan. Although the program has just begun operating, you may have the right to request an independent review even if your dispute occurred last year. If your health plan denied your coverage request since December 1, 2000 because it maintained that the treatment was not medically necessary or was experimental, you should have the right to request an independent review of its decision.

If you've completed your health plan's internal grievance process since that date, the plan should have sent you a packet of information explaining the process. You have four months to request an independent review, so you must send your request to your health plan by October 15, 2002. If you have not yet completed your plan's internal grievance process, but would still like to appeal its decision, you should file a grievance now. In general, you must complete your plan's internal grievance process unless you believe that a delay in getting treatment could jeopardize your life or health. If you are not satisfied with the resolution of your grievance, you may then request an independent review.

In order to ensure that the review will be independent and unbiased, the independent review organizations (IROs) that do the reviews are certified by the state's Office of the Commissioner of Insurance (OCI). At this time, two IROs have been certified and you may choose either IRO to review your complaint. You must then send your request for a review to your health plan. The health plan is required to send your request and any information you submitted to support your request to the IRO that you chose.

When the IRO receives the review request from your health plan, it must verify that it has no conflict of interest either with your health plan or with your doctor or other health care provider. The IRO will then send the file to a medical doctor or other appropriate medical professional who has current experience in treating your medical condition. The IRO has the authority to decide whether your health plan must cover the requested services.

If you have questions on how to request an independent review, contact your health plan's customer service department. It should be able to answer your questions and to provide you with a list of certified IROs and the procedures to follow.

For more information about the independent review process, get the OCI's brochure "Fact Sheet on the Independent Review Process in Wisconsin." It's available on the OCI Web site at http://oci.wi.gov/pub_list/pi-203 or by writing to OCI, P.O. Box 7873, Madison, WI 53707-7873. Contact the OCI toll-free at 1-800-236-8517 or by electronic mail at ocihmo@wisconsin.gov.

By Barbara Belling
Managed Care Specialist
Office of the Commissioner of Insurance