In addition to the internal grievance process that all health plans are required to provide, federal law and Wis. Adm. Code § INS 18.11 requires all health plans to have an independent, external review procedure for review of certain adverse benefit determinations. These generally include denial of, or refusal to pay for, treatment that the insurer considers to be experimental/investigational, not medically necessary, inappropriate such as for health care setting, level of care, effectiveness of a covered benefit or due to a rescission of coverage.  

The Wisconsin Office of the Commissioner of Insurance (OCI) oversees this process. Contact OCI at 1-800-236-8517 or your health plan if you have questions about the independent, external review law.

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