Whenever you have a question or a complaint about your insurance coverage, you can contact the OCI. You can contact the OCI by calling or by e-mailing at the numbers at the end of the article. You can also file a written complaint. The OCI investigates every complaint it receives in order to assist you in resolving your complaint, and to determine if the insurance company is complying with all Wisconsin insurance laws.

Independent Review

If you are not satisfied with the outcome of your grievance, Wisconsin law provides you with an additional way to resolve some disputes involving medical decisions. You or your authorized representative may request that an independent review organization review your health plan's decision. The independent review process provides you with an opportunity to have medical professionals who have no connection to your health plan review your dispute. The independent review organization has the authority to determine whether the treatment should be covered by your health plan.

Other Remedies

If you are not satisfied with the outcome of your appeal, you may wish to discuss your dispute with an attorney. Or you may wish consider filing a claim in small claims court, if your claim is $5,000 or less. Any individual or corporation doing business in Wisconsin can sue or be sued in small claims court. Contact your county clerk of courts for more information on this procedure.

Other Appeals

Wisconsin's protections do not apply to all health plans. However, most plans do have some type of appeal process if your claim is denied.

Private employers who self-fund their benefit plans are subject to federal law. These plans are required to have an appeal process that must be explained in your member materials. The plan generally has up to 60 days to review your appeal, but may take up to 120 days to make its decision.

If you are covered by a government program such as Medicaid, or BadgerCare, these laws do not apply. If you are covered under the Medicaid program, you can contact the Division of Health Care financing in the state's Department of Health and Family Services. If your coverage is through a managed care plan, the HMO is required to have an advocate to assist you in resolving your problem.

General Tips

It's always best to avoid having a problem if possible. One of the best ways to do this is to understand how your plan works before you need to receive care. Remember that no health insurance policy covers all medical expenses, so it is important to know what services are covered under your insurance policy. You can do this by reviewing your policy or certificate of coverage. This document lists the benefits and the limitations of the policy. It will also explain any procedures you need to follow. For example, it is important to understand when you need to have services approved.

If you have any questions about your coverage, call the plan's customer service department.

This article is one of a series written by Barbara Belling, Managed Care Specialist for the Office of the Commissioner of Insurance. She can be reached by electronic mail at ocihmo@wisconsin.gov. The OCI's brochures "Fact Sheet on Managed Care Consumer Protections in Wisconsin," "Managed Care Health Plans in Wisconsin," and "Fact Sheet on the Independent Review Process in Wisconsin" are available toll-free at 800-236-8517 or on the Internet at http://oci.wi.gov/pub_list.htm.

By Barbara Belling
Office of the Commissioner of Insurance