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Independent Review Process in Wisconsin

​​​​​​​​Last Updated: January 24, 2025​

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 review your claim​ or coverage request and make a final decision. Because the reviewer is not affiliated with you or the insurer, the reviewer can conduct an independent and unbiased review of your issue.

  1. An independent review is available when your insurance company denies insurance coverage​ for a medical treatment because it determined the treatment is not medically necessary or it is experimental. This includes denial of your request for out-of-network​ services when you believe the clinical expertise of the out-of-network provider is medically necessary​ but the company does not agree. To qualify for independent review, the treatment must be a covered benefit under the insurance contract.

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

  3. An independent review is available if the insurance company retroactively cancels your health insurance policy​ or certificate. This could happen if the insurance company believes that you did not answer the health questions on the insurance application completely and accurately.

  4. If you and your insurance company 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. An independent review is not available 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 your weight loss treatment covered would not be eligible for independent review, even if you believe the treatment is medically necessary.

  2. An independent review is not available 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. An independent review is not available if you have coverage through Medicare, Medicaid, or another federal plan, or if you are covered through your employer’s self-funded plan. These plans generally have a different appeal​ process, which is explained in your member materials.
In many cases, even if a dispute doesn't qualify for an independent review, you can ask the health insurance company to review your concerns through its internal grievance process.

The insurance company'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 company's final written decision within four months (120 days) of the date the grievance decision was provided to you.

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, including medical records, test results, or other documentation the insurance company may not already have. A letter from your doctor and research articles from medical journals can also be helpful.
  • If someone else is filing on your behalf, you must include a statement signed by you authorizing the person to be your representative.
  • Any other information requested by your insurer.



There is no cost to you for requesting an independent review. Your insurance company is required to pay the IRO’s fees.​

Independent Review Timeline

Generally, you must complete your insurance company's internal grievance procedure before requesting an independent review. However, you do not need to complete the grievance process if both you and the insurance company 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 internal grievance process.

Send your request for an expedited independent review at the same time you send the insurance company 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 that you must first complete the internal grievance process.
Within five business days, the insurance company 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 company 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 insurance company 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 company of its decision no later than 72 hours after receiving the review request.


Independent Review Decisions

The independent review process allows you to have your dispute reviewed by experts who have no connection to your insurance company. 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 insurance company’s decision.
The IRO must consider all the documentation and other information provided by you and the company, including medical or scientific evidence, the applicable insurance contract, and any applicable laws.

It may reverse an insurance company’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 on both you and the insurance company.


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 oci.wi.gov/Complaints. 

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​​


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