Section Ins 18.12 - Independent review organization procedures(1) Independent review organizations shall have, and demonstrate compliance with, written policies and procedures governing all aspects of both the standard review and expedited review processes as described in s. 632.835, Stats., including all of the following:(a) A regulatory compliance program that does all of the following: 1. Tracks applicable independent review laws and regulations.2. Ensures the organization's compliance with applicable laws.3. Maintains a current list of potential conflicts of interest updated on no less than a quarterly basis in addition to conducting a conflict review at the time of each case referral to the organization.(b) A procedure to determine, upon receipt of the referral for review, all of the following: 1. Whether a conflict of interest exists. If a conflict exists, the independent review organization shall provide a written notification to the insurer, the commissioner and the insured, or the insured's authorized representative, within 3 business days stating that a conflict exists and declining to take the review, indicating that a different independent review organization will need to be selected by the insured, or the insured's authorized representative.2. The type of case for which review is sought. The independent review organization shall determine if the case relates to a coverage denial determination or an administrative issue. If the independent review organization determines that the review is not related to a coverage denial determination, the independent review organization shall provide written notification to the commissioner, the insured, or the insured's authorized representative, and the insurer of its determination within 2 business days.3. The specific question or issue that is to be resolved by the independent review process.4. Whether the amount published in accordance with s. Ins 18.105, has been met based upon the type of determination the insurer made. The independent review organization shall calculate the amount that is required to be met, in accordance with s. 632.835(1) (a) 4. and (b) 4., Stats., and s. Ins 18.10(2) (d), as adjusted in accordance with s. 632.835(5) (c), Stats., and s. Ins 18.105, using the actual cost charged the insured without deduction for cost sharing or contractual agreements with providers.5. Whether the case merits standard review or expedited review.(c) Criteria for the number and qualification of reviewers. The criteria must meet the requirements of sub. (4).(d) Procedures to ensure that, upon selection of the reviewer, a file which includes all information necessary to consider the case is provided to the reviewer. In cases where more than one reviewer is assigned to the case by the independent review organization, the independent review organization shall provide an opportunity for the reviewers to discuss the case with one another and shall accept the majority decision of the reviewers.(e) Procedures for consideration of pertinent information for cases referred to independent review organizations regarding an adverse determination, including all of the following: 1. The insured's medical records.2. The attending provider's recommendation.3. The terms of coverage under the insured's health benefit plan.4. Information accumulated regarding the case prior to its referral to independent review, including the rationale for prior review determinations.5. Information submitted to the independent review organization by the referring entity, insured or attending provider.6. Clinical review criteria developed and used by the insurer.7. Medical or scientific evidence including evidence that is determined to be an efficacious treatment or strategy as defined at s. Ins 3.36(3) (c), as appropriate.8. Legal basis, as appropriate.(f) Procedures for consideration of pertinent information for cases referred to the independent review organization regarding experimental treatment determinations including all information required in par. (e) and existing medical or scientific evidence regarding the proposed treatment with respect to effectiveness and efficacy.(g) Policies and procedures to request and accept any additional information that may assist in rendering a determination. Information received by the independent review organization from the insured or attending provider shall be provided to the insurer offering a health benefit plan in order to provide the insurer with the opportunity to reverse its decision.(h) Procedures to ensure that within 2 business days of rendering a determination, the independent review organization shall, in addition to the requirements of s. 632.835(3) (f), Stats., send to the insurer offering a health benefit plan, the insured, or the insured's authorized representative a written notice of the determination that includes all of the following: 1. The question or issue that was referred for review.2. A description of the qualifications of the reviewer or reviewers.3. A clinical rationale or explanation for the independent review organization's determination, including supporting evidence and a clear statement of the decision.4. The decision shall be signed by the case reviewer or, in cases where more than one reviewer is assigned to review the case, the signature of at least one of the reviewers.(i) Procedures to ensure expedited reviews are completed in accordance with s. 632.835(3) (g), Stats., and take into account the insured's health condition. Upon completion of the review, the independent review organization shall provide its decision within one hour, or as expeditiously as practicable, to the insured, or the insured's authorized representative, and the insurer.(j) Procedures to ensure that the decision of the independent review organization is consistent with s. 632.835(3m), Stats.(k) Procedures for determining when the inclusion of an attorney or actuary as a member of a review panel or the advice of an attorney and actuary would provide appropriate and necessary assistance in the review.(2) QUALITY ASSURANCE PROCEDURES. Independent review organizations shall establish, maintain and demonstrate compliance with written quality assurance procedures that promote objective and systematic monitoring and evaluation of the independent review process and that includes, at a minimum, all procedures to ensure the following: (a) That the independent reviews are conducted within the specified time frames and that required notices are provided in a timely manner.(b) That the selection of qualified and impartial clinical peer reviewers to conduct independent reviews on behalf of the independent review organization is achieved, including that the matching of reviewers to specific cases is suitable.(c) The independent review organization shall conduct appropriate training, monitor performance on an ongoing basis and evaluate, no less than annually, each of the reviewers and non-clinical staff.(d) That the confidentiality of personal medical information is maintained in accordance with state and federal law. Access to personal medical information shall be limited to only the information necessary for review of the services under independent review, used solely for the purpose of independent review and shared only with the selected reviewers, the insurer and the insured or the insured's authorized representative.(e) That any person employed by, or under contract with, the independent review organization adheres to the requirements of this section.(f) That management reports are adequate to track and monitor matters described in pars. (a) to (e). (3) ACCESSIBILITY. (a) The independent review organization shall establish a toll-free telephone service to receive information on a 24-hour, 7-days per week, basis. The telephone service selected shall be capable of accepting, recording or providing appropriate instruction to incoming telephone callers during other than normal business hours.(b) The independent review organization shall establish policies and procedures to ensure that services are provided during times other than normal business hours to ensure that the independent review organization meets its obligation under sub. (1) (i). (4) REVIEWER QUALIFICATIONS. (a) In addition to the requirements of s. 632.835(6m), Stats., the independent review organization shall require all clinical peer reviewers assigned to conduct independent reviews to be physicians or other appropriate health care providers whose qualifications are verified at least every 2 years.(b) For coverage denial determinations that include a legal review, the independent review organization shall require legal reviewers assigned to conduct independent reviews be attorneys licensed and in good standing in this state and whose qualifications are verified at least every 2 years.(c) For coverage denial determinations that include review of an underwriting determination, the independent review organization shall require actuaries be assigned to assist in the review and be a member in good standing of the American academy of actuaries and whose qualifications are verified at least every 2 years.(5) CONFLICT OF INTEREST. In addition to the requirements in s. 632.835(6), Stats., all clinical peer, legal and actuary reviewers shall, at least quarterly, provide to the independent review organization a list of potential conflicts of interest.(6) DIRECTOR. (a) Except as provided in par. (b), an independent review organization shall employ or contract with a medical director with professional post-residency experience in direct patient care who holds a current license to practice medicine and who has a clinical specialty appropriate to the type of reviews conducted by the independent review organization.(b) An independent review organization that limits its reviews to matters related to a particular type of health care may employ or contract with a clinical director. The clinical director shall be trained and hold a current license in a medical or health care specialty appropriate to the full scope of the organization's review.(c) The independent review organization shall require the medical director or clinical director to oversee the medical or health care aspects of quality assurance and credentialing programs.(6m) An independent review organization may employ or contract with a law firm, experienced attorney, actuarial entity or experienced actuary to assist in the review of matters related to reformations, rescissions and preexisting condition denial determinations. The independent review organization shall oversee aspects of quality assurance, licensing and expertise of the legal or actuarial reviewer.(7) DELEGATED FUNCTIONS. The independent review organization may delegate or subcontract review functions. Nevertheless, the independent review organization is responsible for the delegated or subcontracted functions, including any violation of law, policy or procedure. In addition, an independent review organization that delegates or subcontracts independent review functions shall provide documentation and verification of all of the following: (a) Written contracts with the subcontractor that delineates with specificity all duties and responsibilities.(b) A review by the independent review organization, on at least an annual basis, of the subcontractor's policies, procedures, and quality assurance program, if relevant to the subcontracted functions.(c) A review by the independent review organization, on at least an annual basis, of the subcontractor's performance and compliance, monitored by the independent review organization, with stated policies, procedures, quality assurance programs and applicable laws.(d) A review by the independent review organization, on at least an annual basis, of the effectiveness of communication and coordination of processes between the independent review organization and the subcontractor.(8) UNBIASED. An independent review organization shall be unbiased. An independent review organization shall establish and maintain procedures to ensure that it is unbiased.Wis. Admin. Code Office of the Commissioner of Insurance Ins 18.12
CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 04-079: am. (1) (b) Register December 2004 No. 588, eff. 1-1-05; CR 10-023: am. (1) (b) 1., 2., (e) 7., (4), (5), cr. (1) (e) 8., (k), (6m) Register September 2010 No. 657, eff. 10-1-10.