Wis. Admin. Code Office of the Commissioner of Insurance § Ins 18.03 - Grievances

Current through March 28, 2022

(1) DEFINITION AND EXPLANATION OF THE GRIEVANCE PROCEDURE.
(a) Each insurer offering a health benefit plan shall incorporate within its policies, certificates and outlines of coverage the definition of a grievance as stated in s. Ins 18.01(4).
(b) An insurer offering a health benefit plan shall develop an internal grievance and expedited grievance procedure that shall be described in each policy and certificate issued to insureds at the time of enrollment or issuance.
(c) In accordance with s. 632.83(2) (a), Stats., an insurer that offers a health benefit plan shall investigate each grievance.
(2) NOTIFICATION OF RIGHT TO APPEAL DETERMINATIONS.
(a) In addition to the requirements under sub. (1), each time an insurer offering a health benefit plan denies a claim or benefit or initiates disenrollment proceedings, the health benefit plan shall notify the affected insured of the right to file a grievance. For purposes of this subchapter, denial or refusal of an insured's request of the insurer for a referral shall be considered a denial of a claim or benefit.
(b) When notifying the insured of their right to grieve the denial, determination, or initiation of disenrollment, an insurer offering a health benefit plan shall either direct the insured to the policy or certificate section that delineates the procedure for filing a grievance or shall describe, in detail, the grievance procedure to the insured. The notification shall also state the specific reason for the denial, determination or initiation of disenrollment.
(c)
1. An insurer offering a health benefit plan that is a defined network plan as defined in s. 609.01(1b), Stats., other than a preferred provider plan as defined in s. 609.01(4), Stats., shall do all of the following:
a. Include in each contract between it and its providers, provider networks, and within each agreement governing the administration of provider services, a provision that requires the contracting entity to promptly respond to complaints and grievances filed with the insurer to facilitate resolution.
b. Require contracted entities that subcontract for the provision of services, including subcontracts with health care providers, to incorporate within their contracts a requirement that the providers promptly respond to complaints and grievances filed with the insurer to facilitate resolution.
c. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.
d. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.
2. An insurer offering a health benefit plan that is a preferred provider plan as defined in s. 609.01(4), Stats., shall do all of the following:
a. Include in each contract between it and its providers, provider networks and within each agreement governing the administration of provider services, a provision that requires the contracting entity to promptly provide the insurer the information necessary to permit the insurer to respond to complaints or grievances described under subd. 2. c.
b. Require contracted entities that subcontract for the provision of services, to incorporate within their contracts, including subcontracts with health care providers, a requirement that the subcontractor promptly provide the insurer with the information necessary to respond to complaints or grievances described under subd. 2. c.
c. Include in its description of the grievance process required under sub. (1), a clear statement that an insured may submit to the insurer offering a health benefit plan a complaint or grievance relating to covered services provided by a participating health care provider.
d. Process and respond to a complaint or grievance described under subd. 2. c.
e. Maintain records and reports reasonably necessary to monitor compliance with the contractual provisions required under this paragraph.
f. Take prompt action to compel correction of non-compliance with contractual provisions required under this paragraph.
(d) If the insurer offering a health benefit plan is either a health maintenance organization as defined in s. 609.01(2), Stats., or a limited service health organization as defined by s. 609.01(3), Stats., and the insurer initiates disenrollment proceedings, the insurer shall additionally comply with s. Ins 9.39.
(3) GRIEVANCE PROCEDURE. The grievance procedure utilized by an insurer offering a health benefit plan shall include all of the following:
(a) A method whereby the insured who filed the grievance, or the insured's authorized representative, has the right to appear in person before the grievance panel to present written or oral information. The insurer shall permit the grievant to submit written questions to the person or persons responsible for making the determination that resulted in the denial, determination, or initiation of disenrollment unless the insurer permits the insured or insured's authorized representative to meet with and question the decision maker or makers.
(b) A written notification to the insured of the time and place of the grievance meeting at least 7 calendar days before the meeting.
(c) Reasonable accommodations to allow the insured, or the insured's authorized representative, to participate in the meeting.
(d) The grievance panel shall comply with the requirements of s. 632.83(3) (b), Stats., and shall not include the person who ultimately made the initial determination. If the panel consists of at least three persons, the panel may then include no more than one subordinate of the person who ultimately made the initial determination. The panel may, however, consult with the ultimate initial decision-maker.
(e) The insured member of the panel shall not be an employee of the plan, to the extent possible.
(f) Consultation with a licensed health care provider with expertise in the field relating to the grievance, if appropriate.
(g) The panel's written decision to the insured as described in s. 632.83(3) (d), Stats., shall be signed by one voting member of the panel and include a written description of position titles of panel members involved in making the decision.
(4) RECEIPT OF GRIEVANCE ACKNOWLEDGMENT. An insurer offering a health benefit plan shall, within 5 business days of receipt of a grievance, deliver or deposit in the mail a written acknowledgment to the insured or the insured's authorized representative confirming receipt of the grievance.
(5) AUTHORIZATION FOR RELEASE OF INFORMATION.
(a) An insurer offering a health benefit plan may require a written expression of authorization for representation from a person acting as the insured's authorized representative unless any of the following applies:
1. The person is authorized by law to act on behalf of the insured.
2. The insured is unable to give consent and the person is a spouse, family member or the treating provider.
3. The grievance is an expedited grievance and the person represents that the insured has verbally given authorization to represent the insured.
(b) An insurer offering a health benefit plan shall process a grievance without requiring written authorization unless the insurer, in its acknowledgement to the person under sub. (4), clearly and prominently does all of the following:
1. Notifies the person that, unless an exception under par. (a) applies, the grievance will not be processed until the insurer receives a written authorization.
2. Requests written authorization from the person.
3. Provides the person with a form the insured may use to give written authorization. An insured may, but is not required to, use the insurer's form to give written authorization.
(c) An insurer offering a health benefit plan shall accept under par. (a) any written expression of authorization without requiring specific form, language or format.
(d) An insurer offering a health benefit plan shall include in its acknowledgement of receipt of a grievance filed by an authorized representative a clear and prominent notice that health care information or medical records may be disclosed only if permitted by law. The acknowledgement shall state that unless otherwise permitted under applicable law, including the Health Insurance Portability and Accountability Act of 1996, U.S. PL 104-191, ss. 51.30, 146.82 to 146.84, and 610.70, Stats., and ch. Ins 25, informed consent is required and the acknowledgement shall include an informed consent form for that purpose. An insurer offering a health benefit plan may withhold health care information or medical records from an authorized representative, including information contained in its resolution of the grievance, but only if disclosure is prohibited by law. An insurer offering a health benefit plan shall process a grievance submitted by an authorized representative regardless of whether health care information or medical records may be disclosed to the authorized representative under applicable law.
(6) RESOLUTION OF A GRIEVANCE. An insurer offering a health benefit plan shall resolve a grievance:
(a) For a grievance that is a review of a benefit determination that is subject to 29 CFR 2560.503-1, within the time provided under 29 CFR 2560- 503 - 1(i).
(b) For any grievance not subject to par. (a), within 30 calendar days of receiving the grievance. If the insurer offering a health benefit plan is unable to resolve the grievance within 30 calendar days, the time period may be extended an additional 30 calendar days, if the insurer provides a written notification to the insured and the insured's authorized representative, if applicable, of all of the following:
1. That the insurer has not resolved the grievance.
2. When resolution of the grievance may be expected.
3. The reason additional time is needed.
(7) COMMISSIONER ANNUAL REPORT. The commissioner shall by June 1 of each year prepare a report that summarizes grievance experience reports received by the commissioner from insurers offering health benefit plans. The report shall also summarize OCI complaints involving the insurer offering health benefit plans that were received by the office during the previous calendar year.

Notes

Wis. Admin. Code Office of the Commissioner of Insurance § Ins 18.03
CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; corrections in (2) (c) 1. and (5) (d) made under s. 13.93(2m) (b) 7, Stats., Register December 2004 No. 588; CR 05-059: am. (2) (c) 1. Register February 2006 No. 602, eff. 3-1-06.

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