Date: April 3, 2002
For more information contact: Kyle Richmond (608) 267-9336 or kyle.richmond@oci.state.wi.us

Madison, WI--Wisconsin residents with health insurance will soon be able to appeal denials of their claims to an external third party.

The Office of the Commissioner of Insurance (OCI) has certified two companies this week to weigh external appeals from health policyholders. Those independent review organizations (IRO) can begin work on June 15, or 60 days after certification notice is published by the state. Before that date the state's health benefit plans will notify their policyholders that the appeal process is in place.

"A very important part of Wisconsin's consumer protection net will be secured through the independent review option," said Barbara Belling, Managed Care Specialist for the Office of the Commissioner of Insurance.

Two situations qualify a claim for an appeal. First, when a policyholder's claim is denied, or partially denied, because the health plan determined treatment wasn't medically necessary. Second, when the claim is denied because the treatment was determined to be experimental.

Policyholders are required to file a grievance with their health plans before appealing to in IRO. The grievance procedure--an internal complaint process--is required of every health benefit plan by law. If appeal of the plan's decision is denied through the grievance process, the policyholder can proceed with an independent review. If the person's situation necessitates an expedited grievance, or if the health plan and insured agree, the individual may bypass internal grievance.

"It's important to pursue the grievance process before moving to an external appeal," Belling said. "That process is free and mandated by Wisconsin law."

The amount of claim in dispute must be a minimum of $250 to be eligible for independent review. The cost to file for independent review is $25, a fee that will be refunded if the insurer's denial is overturned by the IRO. Policyholders should contact their insurance companies to request independent review, and contact the OCI if they have questions or problems.

Once a request for independent review has been filed, the IRO has 30 days to issue a decision, unless the circumstance for review is urgent. The IRO will consider medical records, documentation and other evidence in making its decision. The IRO's decision will be legally binding on both the complainant and the insurer.

Complainants will choose among all independent review organizations certified in the state. The OCI will certify addition independent review organization that meet requirements of state statute. All Wisconsin-certified IROs are required to report to the OCI annually about the type and results of the business they do in the state.

There are now 41 other states with some version of independent review.

For more information about the independent review process, see the OCI's Web site at oci.wi.gov or by writing to OCI, P.O. Box 7873, Madison, WI 53707-7873. Contact the OCI toll-free at 1-800-236-8579 or by electronic mail at ociinformation@wisconsin.gov.