Consumer Guide to Health Care
The Independent Review Process in Wisconsin
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Department of Health Services does not testify to, sponsor,
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If you are having problems with your health insurance you may be able to use
Wisconsin’s independent review process. This process is available to you if you
meet all of the following conditions:
-
Your claim has been denied or partially denied because the health plan determined
treatment wasn’t medically necessary or because the treatment was determined to
be experimental.
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Your claim was denied on or after December 1, 2000.
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In most cases, you must first file a grievance with your health plan.
If your situation necessitates an expedited grievance, or if you and the
health plan agree, you may bypass your plan’s internal grievance procedure.
Under the independent review process, you select an independent review organization (IRO) from
among those certified by the Wisconsin Office of the Commissioner of Insurance. The amount of
the claim must be at least $250. The cost to file is $25, which will be refunded if your denial
is overturned. The IRO’s decision will be legally binding on both the complainant and the insurer.
More information
about the independent review process is available from Wisconsin’s Office of the
Commissioner of Insurance.
Back to the How to Deal with Problems with your Health Insurance
Page
Last Revised: July 29, 2008
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