An insurer offering a health benefit plan shall comply with all of the following requirements:

1. (1) Each record of each complaint and grievance submitted to the insurer shall be kept and retained for a period of at least 3 years. These records shall be maintained at the insurer’s home or principal office and shall be available for review during examinations by or on request of the commissioner or office.

2. (2) Submit a grievance experience report required by s. 632.83 (2) (c), Stats., to the commissioner by March 1 of each year. The report shall provide information on all grievances received during the previous calendar year. The report shall be in a form prescribed by the commissioner and, at a minimum, shall classify grievances into the following categories:

   1. (a) Plan administration including plan marketing, policyholder service, billing, underwriting and similar administrative functions.

   2. (b) Benefit services including denial of a benefit, denial of experimental treatment, quality of care, refusal to refer insureds or to provide requested services.

      Note: A copy of the grievance experience report form OCI26-007, required under par. (2), may be obtained from the Office of the Commissioner of Insurance, P. O. Box 7873, Madison WI 53707-7873.

History

History: CR 00-169: cr. Register November 2001 No. 551, eff. 12-1-01.