Small picture of Wisconsin capital.State of Wisconsin, Office of the Commissioner of Insurance
Abbreviation for Office of the Commissioner of Insurance, O C I.
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   Independent Review Organizations

Independent Review Requests
for Calendar Year 2003

According to State insurance law, health insurance claimants have a right to an independent review of an adverse decision by an insurer of their claims. These reviews are carried out by Independent Review Organizations (IROs) registered with OCI. Every year, IROs certified to do reviews in Wisconsin are required to submit to the Office of the Commissioner of Insurance a report for the prior calendar year's experience. The independent review process allows a consumer to appeal some health insurance claims denials to an independent third party. The results from the reports for calendar year 2003 are summarized below.

A total of 220 review requests were submitted to the 5 certified IRO's for consideration. In 42 cases, the IRO declined the request. A review request may be declined for a number of reasons. If the request does not involve a question of whether the treatment is medically necessary or whether it is experimental, it is not eligible for an independent review. An IRO may also decline a review if it determines that it may have a potential conflict of interest or if it receives a request directly from a consumer rather than from the insurer.

The last column of the summary lists the average number of days that the IROs needed to complete a review. Although the time needed to make a decision varies depending on the complexity of the case, on average an IRO took 18 days from the date it received the review request to make a decision.

OCI will be refining this report as more data becomes available and as we get suggestions for improvement to the report from those who use it. You are encouraged to contact OCI with your suggestions.

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.

Independent Review Organizations Certified to Perform Independent Reviews in Wisconsin

Name of
Insurance Company		Total Review Requests ReceivedIndependent Review OrganizationsNumber of Decisions
that IRO:		Average Number of Days to Resolve
IPROMaximus
-CHDR		Medical
Review
Inst. of
America		PermedionPrestUpheldReversed
Aetna Life Ins Co1001001010 days
American Family Mutual Ins Co*10100000N/A
Blue Cross & Blue Shield United of WI*2414811012521 days
Central States Health & Life*10100000N/A
Compcare Health Services Ins Corp*10114402620 days
Dean Health Plan*6002314021 days
Fortis Benefits Ins Co1001001012 days
Fortis Ins Co3003003012 days
Group Health Coop of Eau Claire*2011001037 days
Group Health Coop of South Central Wis2000202022 days
Gundersen Lutheran Health Plan*4010302011 days
HIRSP1000100117 days
Humana Wisconsin Health Organization Ins Corp*4002203022 days
MercyCare Ins Co*8024115013 days
Midwest Security Life Ins Co192368011817 days
Network Health Plan*10212325222 days
Nippon Life Ins Co*10010000N/A
Pekin Life Ins Co2000202021 days
Physicians Plus Ins Corp4001304013 days
PHP Insurance Plan*8112404212 days
Security Health Plan3100202132 days
Touchpoint Health Plan*35659150151316 days
Trustmark Ins Co200200118 days
UnitedHealthCare of Wis1000101020 days
Unity Health Plans Ins Corp2011001114 days
Valley Health Plan1010001028 days
WEA Ins Corp5102205018 days
Wisconsin Auto & Truck Dealers Ins Corp*7004305017 days
Wisconsin Physicians Service Ins Corp*506127250222120 days
Totals2182135639541156118 days
*Total review requests received does not equal total number of decisions because Independent Review Organization declined one or more cases.

Updated: August 30, 2004
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