Wis. Admin. Code Office of the Commissioner of Insurance § Ins 3.67 - Benefit appeals under certain policies

Current through November 29, 2021

(1) DEFINITIONS. In this section:

(a) "Defined network plan" has the meaning provided under s. 609.01(1b), Stats.

(am) "Expedited request" means a request where the standard resolution process may include any of the following:

1. Serious jeopardy to the life or health of the enrollee or the ability of the enrollee to regain maximum function.

2. In the opinion of a physician with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

3. Is determined to be an expedited request by a physician with knowledge of the enrollee's medical condition.

(b) "Grievance" means any dissatisfaction with the provision of services or claims practices of an insurer offering a defined network plan, limited service health organization or preferred provider plan or administration of a defined network plan, limited service health organization or preferred provider plan by the insurer that is expressed in writing to the insurer by, or on behalf of, an enrollee.

(c) "Health care plan" has the meaning provided under s. 628.36(2) (a) 1, Stats., including fixed indemnity and specified disease insurance but does not include coverage ancillary to property and casualty insurance and Medicare + Choice plans.

(d) "Limited service health organization" has the meaning provided under s. 609.01(3), Stats.

(f) "Self-insured plan" has the meaning provided under s. 632.85(1) (c), Stats.

(2)DRUGS AND DEVICES. A health care plan or self-insured plan that provides coverage of only certain specified prescription drugs or devices shall develop a process through which an enrollee's physician may present medical evidence to obtain an individual patient exception for coverage of a prescription drug or device.

(3)COVERAGE OF EXPERIMENTAL TREATMENTS.

(a) Any coverage limitations for experimental treatment shall be defined and clearly disclosed in every policy issued by a health care plan or self-insured plan in accordance with s. 632.855(2), Stats.

(b) A health care plan or self-insured plan that limits coverage for experimental treatment shall have an internal procedure consistent with s. 632.855(3), Stats., including issuing a written coverage decision within 5 business days of receipt of the request.

(4)APPEAL PROCEDURE. The procedure for defined network plan enrollees to appeal a decision under subs. (2) and (3) is delineated under s. Ins 18.03. For other health care plans, the appeal procedure established under this section shall include all of the following:

(a) The opportunity for the policyholder or certificate holder, or an authorized representative of the policyholder or certificate holder, to submit a written request, which may be in any form and which may include supporting material, for review by the insurer of the denial of any benefits under the policy.

(b) If an insurer denies any benefit under sub. (2) or (3), the insurer shall, at the time the insurer gives notice of the denial of benefits, provide the policyholder with a written description of the appeal process.

(c) The health care plan or self-insured plan shall acknowledge, in writing, a request for review of coverage under sub. (2), within 5 business days of receiving it.

(d) Within 30 calendar days after receiving the request under sub. (2) or (3), the health care plan or self-insured plan shall provide the disposition of the review and notify the person who submitted the request for review of the results of the review.

(e) A process to resolve an expedited request for review as expeditiously as the health condition requires but not to exceed 72 hours from the receipt of a substantially completed request under sub. (2) or (3).

(f) An insurer shall describe the procedure established under this subsection in every policy, group certificate and outline of coverage issued in connection with a health care plan.

(g) Each insurer offering a health care plan shall keep together, at its home or principal office, all records of appeals under this subsection. The insurer shall make these records available for review during examinations or at the request of the commissioner.

Notes

Wis. Admin. Code Office of the Commissioner of Insurance § Ins 3.67

Cr. Register, February, 2000, No. 530, eff. 3-1-00; correction in (1) (e) made under s. 13.93(2m) (b) 7, Stats., Register December 2002 No. 564; correction in (4) made under s. 13.93(2m) (b) 7, Stats., Register April 2003 No. 568; CR 05-059: renum. (1) (a) and (e) to be (1) (am) and (a), am. (1) (a) and (b) and (4) (intro.) Register February 2006 No. 602, eff. 3-1-06.