What is independent review?
Independent review lets a medical expert with no connection to your insurer review certain coverage denials. Wisconsin law requires insurers to make this process available through OCI-certified independent review organizations (IROs) that you select (Wis. Stat. § 632.835).
For most medical-necessity and experimental/investigational disputes, the IRO decision is binding on you and the insurer. The insurer pays IRO fees—you pay nothing.
General overview: Appeals roadmap. Complete Wisconsin internal appeals first unless you agree to skip grievance or qualify for expedited review.
Who can use Wisconsin review?
Wisconsin independent review under § 632.835 generally applies when:
- You have OCI-regulated commercial coverage (many HealthCare.gov and fully insured employer plans)
- The denial is a coverage denial determination—medical necessity, experimental treatment, certain pre-existing condition exclusions, or policy rescission (subject to dollar thresholds in statute)
- You exhausted internal grievance—or qualify to bypass it
Usually does not apply to:
- Medicare, Medicaid (BadgerCare), and federal plans
- Self-funded ERISA employer plans (federal external review may apply)
- Pure contractual exclusions or administrative denials (premium payment, eligibility coding)
OCI maintains a list of certified IROs.
Deadlines & exhaustion
Four months (§ 632.835(2)(c))
Request independent review within 4 months (120 days) after you receive notice of grievance disposition under § 632.83(3)(d), unless you agree with the insurer to proceed directly to review.
Exhaust internal grievance first
Complete the insurer's § 632.83 grievance unless you and the insurer agree to skip it, or the IRO approves bypass for urgent health conditions (§ 632.835(2)(d)).
Select your IRO
You must choose a certified IRO from OCI's list and notify the insurer in writing of your selected organization (§ 632.835(3)(a)).
How to file
- Complete internal grievance and obtain a final denial with independent review rights when required.
- Send a written request to the address in your final grievance decision within 4 months.
- Name the OCI-certified IROyou selected (see OCI's IRO list).
- Include your explanation, medical records, physician letter, and authorized representative form if someone else is filing.
- For expedited review, send the expedited grievance and independent review requests together; the IRO decides if immediate review is warranted.
OCI guide: Independent review process (PI-203).
Links hub: Wisconsin external appeals links.
How long it takes
- Insurer sends records to IRO within 5 business days; IRO may request more information (§ 632.835(3)(b)–(c))
- Standard review: IRO decision within 30 business days after all deadlines expire (§ 632.835(3)(f))
- Expedited review: insurer sends records within 1 day; IRO decides within 72 hours (§ 632.835(3)(g))
- Experimental treatment: special clinical reviewer process; expedited path within 48 hours after IRO receives opinions (§ 632.835(3m)(b), (8))
Is the decision binding?
For adverse determinations and experimental treatment determinations, the IRO decision is generally binding on you and the insurer (§ 632.835(3)(f)). Pre-existing condition and rescission decisions may not be binding on the insured—check your notice and statute.
If the IRO reverses the denial, the insurer must immediately approve coverage.
Medicaid & Medicare
BadgerCare / Medicaid: Exhaust MCO appeal, then request a fair hearing within 90 days (DHS F-00236)—not § 632.835 commercial IRO review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS; Wisconsin SHIP help at Wisconsin SHIP.
More: Medicaid managed care · Medicare appeals.