Independent Review Process
Minimum Adjusted Dollar Amount
PLEASE NOTE: Both state and federal law give individuals the right to appeal some health plan denials to an independent review organization. This chart applies to health plans that are only subject to Wisconsin's independent review laws. It does not apply to most health plans. Health plans subject to the federal external review process do not require the dispute to involve a minimum cost. Refer to your policy/certificate or contact your plan's customer service department to determine whether this chart applies to you.
Wisconsin's independent review process may help you resolve your dispute with your health insurance plan's coverage denial determination. The independent review process allows you to have a medical expert with no connection to your health plan review the health plan's decision. In order to be eligible for an independent review involving a coverage denial based on a medical necessity or experimental treatment determination, the dispute must involve a minimum amount of money. This minimum cost or expected cost of the treatment is adjusted annually to reflect the changes in the consumer price index as determined by the United States Department of Labor.
The chart below lists the minimum costs and related time periods that the given amounts will be in effect. To determine the amount that applies to your dispute, use the later of: the last date that treatment was received or the date that the insurer mailed its written denial.
|Effective Beginning||End Date||Minimum Adjusted|
|June 15, 2002||December 31, 2004||$250|
|January 1, 2005*||December 31, 2005||$256|
|January 1, 2006||December 31, 2006||$268|
|January 1, 2007||December 31, 2007||$274|
|January 1, 2008||December 31, 2008||$282|
|January 1, 2009||December 31, 2009||$296|
|January 1, 2010||December 31, 2010||$292|
|January 1, 2011||December 31, 2011||$295|
|January 1, 2012||December 31, 2012||$307|
|January 1, 2013||$313|
*Administrative rule implementing change in minimum cost became effective January 1, 2005.
The Fact Sheet on the Independent Review Process in Wisconsin provides more information about this process. It can be found at http://oci.wi.gov/pub_list/pi-203.htm. You can also contact OCI at the address on the How to Contact Us page to request a copy.