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 the grievance, you have an additional way to resolve some disputes involving medical decisions. You or your authorized representative may request that an Independent Review Organization (IRO) review your health plan's decision.
The independent review process provides you with an opportunity to have medical professionals who have no connection to your health plan review your dispute. You choose the IRO from a list of review organizations certified by the OCI. The IRO assigns your dispute to a clinical peer reviewer who is an expert in the treatment of your medical condition. The IRO has the authority to determine whether the treatment should be covered by your health plan.
The independent reviews are conducted by IROs that are certified by the OCI. In order to be certified the IRO must demonstrate that it is unbiased and that it has procedures to ensure that its clinical peer reviewers are qualified and independent.
In most cases, you will need to complete your health plan's internal grievance procedure. After you receive the insurer's final decision on your grievance, choose an IRO from the list provided by the insurer. Then send a written request for independent review to the insurance company.
Your health plan should provide you with information on your right to request an independent review in its written materials. You can also call the health plan at its toll-free number and request information on independent review.
For more information on the independent review process, call the OCI and request a copy of Fact Sheet on the Independent Review Process in Wisconsin. A copy is also available on OCI's Web site at http://oci.wi.gov/pub_list/pi-203.htm.