Independent Review Process in Wisconsin

​​​​​Last Updated: November 18, 2020

Printable version of publication: Independent Review Process in Wisconsin FAQs 

This fact sheet provides general information on the independent review​ process in Wisconsin. If you have specific questions on how it may apply to your situation, please contact your insurance company or the Office of the Commissioner of Insurance (OCI).​

Requesting an Independent Review

An independent review is a process allowing an outside expert to provide a second look at your claim. Because the reviewer is not affiliated with you or the insurer, the reviewer can conduct an independent and unbiased review of your claim.
  1. An independent review is available when your health plan denies coverage for treatment because it maintains the treatment is not medically necessary or it is experimental. This includes a denial of your request for out-of-network services when you believe the clinical expertise of the out-of-network provider is medically necessary​. The treatment must be a covered benefit under the insurance contract.

  2. An independent review is available when your health plan denies you coverage for treatment based on a preexisting condition exclusion.

  3. You may request an independent review if the insurer rescinds your health insurance policy or certificate. Rescission means the insurer retroactively cancels your policy or modifies the terms of the policy because it claims that you did not answer the health questions on the insurance application completely and accurately.

  4. If you and your insurer disagree about whether your dispute is eligible for independent review, you may request it be sent to an Independent Review Organization (IRO). The IRO will decide if it has the authority to do the review.

  1. You may not request an independent review if the requested treatment is not a covered benefit. For example, if your policy specifically excludes coverage​ of weight loss treatments, your request to have the insurer cover your weight loss treatment would not be eligible for independent review, even if you believe the treatment is medically necessary.

  2. If your dispute involves an administrative issue such as whether your premium was paid on time, it is not eligible for an independent review. However, you can ask the insurer to review your concerns through its internal grievance process.

  3. If you have coverage through Medicare, Medicaid, or another federal plan, or if you are covered through your employer’s self-funded plan, you are not eligible to request the independent review described in this publication. These plans generally have a different appeal process, which is explained in your member materials.

The insurer’s final written decision on your grievance should include a notice explaining how to request an independent review​. Send your written request for independent review to the address provided in the insurer’s final written decision within four months of the date the grievance procedure was completed.

Be sure to include:
  • Your name, address, and phone number
  • An explanation of why you believe the treatment should be covered
  • Any additional information or documentation supporting your position
  • If someone else is filing on your behalf, a statement signed by you authorizing the person to be your representative
  • Any other information requested by your insurer

You may provide the IRO with any information you think will support your case. This may include your medical records and test results, a letter from your physician, and research articles from peer-reviewed medical journals.​
There is no cost to you for requesting an independent review. Your health plan is required to pay the IRO’s fees.


Independent Review Timeline

Generally, you must complete your health plan’s internal grievance procedure before requesting an independent review. However, you do not need to complete this process if both you and the insurer agree to proceed directly to an independent review or if you need immediate medical care.

If you need immediate medical treatment and believe the time for resolving an internal grievance will jeopardize your life or health, you may ask to bypass the insurer’s internal grievance process.

Send your request for an expedited independent review at the same time you send the insurer your expedited grievance request. The IRO’s medical director or another medical professional will review your request and decide if an immediate review is needed. If so, it will review your dispute on an expedited basis.

If the IRO decides your health condition does not require its immediate review, it will notify you to first complete the internal grievance process.
Within five business days, the insurer must send to the IRO:
  • all relevant medical records and other documentation used in making its decision
  • all documentation you sent to support your request
The IRO then has five business days to request any additional information it may need from the insurer or you, and no more than 30 business days to make its decision.

If the IRO determines this time could jeopardize your life or health, the insurer must send its documentation within one day and the IRO then has two business days to request any additional information. The IRO must notify you and the insurer of its decision no later than 72 hours after receiving the review request.



I
ndependent Review Decisions

The independent review process allows you to have your dispute reviewed by experts who have no connection to your health plan. The IRO assigns your dispute to a clinical peer reviewer who is an expert in the treatment of your medical condition. The clinical peer reviewer is generally a board-certified physician or another appropriate medical professional.

In some cases, the IRO will also consult with an attorney or other insurance expert. The IRO has the authority to uphold or reverse the health plan’s decision.
The IRO must consider all the documentation and other information provided by you and the insurer, including medical or scientific evidence, the applicable insurance contract, and any legal bases.

It may reverse an insurer’s denial based on an experimental treatment determination if it finds that the treatment is approved by the FDA, when required, and when medically and scientifically accepted evidence shows that the treatment is proven safe and can be expected to produce greater benefits than the standard treatment without posing a greater adverse risk.

Yes, the decision of the IRO is binding.



Contact Information

Your insurer’s customer service department should be able to answer any questions you may have regarding the independent review process.

Additional information on the federal external review process may be found from the U.S. Department of Health and Human Services at The Center for Consumer Information & Insurance Oversight’s website.

For more information on the entire appeals process, see the Health Insurance Grievances and Complaints​ publication.

If you have a specific complaint about your insurance, you should first attempt to resolve your concerns with your insurance agent or with the company involved in your dispute. If you do not get satisfactory answers from the agent or company, contact OCI. You can find a complaint form at ociaccess.oci.wi.gov/complaints/public/

OCI Contact Information
(608) 266-0103 (in Madison) or 1-800-236-8517 (Statewide)
Deaf or hearing or speech impaired callers may reach OCI through WI TRS

Office of the Commissioner of Insurance
P.O. Box 7873 
Madison, WI 53707-7873

Always include your name and phone number.


Independent Review Organizations Certified to Perform Independent Reviews in Wisconsin

Further questions regarding IROs may be directed to ocihmo@wisconsin.gov