Independent Review Process - Denied Health Claim

Last Updated: December 8, 2021​

Wisconsin’s independent review process provides consumers with the opportunity to resolve some coverage disputes through an independent review organization (IRO) that has no connection to their health plan. The health plan's coverage denial must be based on an adverse determination or an experimental treatment determination. The IRO has the​ authority to determine whether the health plan must provide coverage of the medical treatment or service. See the Office of the Commissioner of Insurance publication Fact Sheet on the Independent Review Process in Wisconsin​ for a description of a consumer's right to appeal a health plan's decision to an independent medical expert or Independent Review Organizations Certified to Perform Independent Review in Wisconsin to see a list of organizations that have been certified as IROs in Wisconsin.

Independent Review Annual Reports​

Every year, IROs certified to do reviews in Wisconsin are required to submit to OCI an annual report for the prior calendar year's experience. The independent review process allows a consumer to appeal some health insurance claim denials to an independent third party.

Independent Review Process Minimum Adjusted Dollar Amount

​The Independent Review Process Minimum Adjusted Dollar Amount 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.