Section Ins 18.16 - Independent review organization reporting requirements(1) An independent review organization shall maintain records on all independent review activity during each calendar year and submit a report to the commissioner, on a form prescribed by the commissioner, by March 1 of each year for the prior calendar year's experience. Records shall be maintained so that, at a minimum, they satisfy the reporting requirements to the commissioner and shall be retained for at least 3 years.(2) The annual report shall include all of the following information on an aggregate basis, by insurer and by insurer and insurance product name: (a) The total number of requests for independent review received.(b) The total number of requests for independent review declined and the reason for the declination, including whether the request was a qualified request or within the scope of the health benefit plan policy.(c) The total number of requests for expedited independent review that the independent review organization declined to handle in an expedited timeframe, including whether the request was a qualified request or within the scope of the health benefit plan policy.(d) The number of independent reviews that were done in an expedited manner and the results of those reviews.(e) The number of requests for independent review resolved and, of those resolved, the number resolved upholding the coverage denial determination by the insurer and the number resolved reversing the coverage denial determination by the insurer. (em) The names and specialty of the reviewers participating in reviews conducted during the year. The listing shall include the name of any attorney or actuary or the respective firm, who participated in the reviews.(f) The average length of time for resolution.(g) A detailed summary of cases including a synopsis of facts, rationale for decision and key evidence relied upon to reach the reviewer's decision. The summary shall also include the types of cases or coverage for which an independent review was sought.(h) The cost of reviews both in the aggregate and on a case by case basis.(i) The number of independent reviews that were terminated as the result of reconsideration by the insurer offering a health benefit plan of its coverage denial determination after the receipt of additional information from the insured, the insured's authorized representative, or other appropriate sources.(j) Any other information the commissioner requests.Wis. Admin. Code Office of the Commissioner of Insurance Ins 18.16
CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01; CR 10-023: am. (2) (e), (i), cr. (2) (em) Register September 2010 No. 657, eff. 10-1-10.