Wis. Admin. Code Office of the Commissioner of Insurance Ins 18.10

Current through November 25, 2024

Section Ins 18.10 - Definitions

In addition to the definitions in s. 632.835(1), Stats., in this subchapter:

(1) "Adverse determination" has the meaning as defined in s. 632.835(1) (a), Stats. This includes the denial of a request for a referral for out-of-network services when the insured requests health care services from a provider that does not participate in the insurer's provider network because the clinical expertise of the provider may be medically necessary for treatment of the insured's medical condition and that expertise is not available in the insurer's provider network.

(2) "Experimental treatment determination" means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:

(a) A proposed treatment has been reviewed.

(b) Based on the information provided, the treatment under par. (a) is determined to be experimental under the terms of the health benefit plan.

(c) Based on the information provided, the insurer that issued the health benefit plan denied the treatment under par. (a) or payment for the treatment under par. (a).

(d) Pursuant to s. 632.835(5) (c), Stats., the cost or expected cost of the denied treatment or payment exceeds, or will exceed during the course of the treatment, the amount published in accordance with s. Ins 18.105.

(3) "Health benefit plan" has the meaning provided in s. 632.835(1) (c), Stats., and includes Medicare supplement and replacement plans as defined in s. 600.03(28p) and (28r), Stats., and s. Ins 3.39(3) (v) and (w). Health benefit plan includes Medicare cost and select plans but does not include Medicare Advantage plans.

(4) "Medical or scientific evidence" means information from any of the following sources:

(a) Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.

(b) Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline and MEDLARS database Health Services Technology Assessment Research (HSTAR).

(c) Medical journals recognized by the Secretary of Health and Human Services under 42 USC 1320 c et. seq. of the federal Social Security Act.

(d) Any of the following standard reference compendia most current edition in publication at the time of the dispute:

1. The American Hospital Formulary Service - Drug Information.

2. The Center for Drug Evaluation and Research History.

3. The ADA/PDR Guide to Dental Therapeutics, current edition.

4. The United States Pharmacopeia - National Formulary.

(e) Findings, studies or research conducted by, or under the auspices of, federal governmental agencies and nationally recognized federal research institutes, including:

1. The federal Agency for Healthcare Research and Quality.

2. The National Institutes of Health.

3. The National Cancer Institute.

4. The National Academy of Sciences.

5. The Health Care Financing Administration.

6. Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services.

7. Any other medical or scientific evidence that is comparable to the sources listed in this paragraph.

(4e) "Preexisting condition exclusion denial determination" has the meaning as defined in s. 632.835(1) (cm), Stats.

(4m) "Legal basis" means information from any of the following sources:

(a) The most current version of The American Journal of Jurisprudence.

(b) United States 7th Judicial Circuit Court decisions.

(c) Wisconsin statutory and common law.

(d) The terms of the insurance contract applicable for the period of coverage in dispute.

(5) "Unbiased" means an independent review organization that complies with all of the following:

(a) Section 632.835(6), Stats.

(b) The independent review organization does not provide incentives of any kind, including financial incentives, to providers or consumers as inducements for selection as the independent review organization.

(c) The independent review organization does not directly or indirectly receive any compensation, in any form, related to a review, other than the compensation permitted under this subchapter and s. 632.835, Stats.

(d) The independent review organization does not promote, to providers, consumers or insurers any of the following:

1. A pattern of favorable results or a pattern of favorable results on a particular treatment or subject.

2. An association with a class of providers, consumers or insurers.

3. A bias favorable to a class of providers, consumers or insurers.

(e) The independent review organization does not have a pattern of decisions that are unsupported by substantial evidence.

Wis. Admin. Code Office of the Commissioner of Insurance Ins 18.10

CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 04-079: am. (2) (d) Register December 2004 No. 588, eff. 1-1-05; CR 04-121: am. (3) Register June 2005 No. 594, eff. 7-1-05; CR 10-023: am. (4) (d), cr. (4e) and (4m) Register September 2010 No. 657, eff. 10-1-10.