What is an internal appeal?
An internal appeal (grievance) asks the health insurer to reconsider an adverse benefit determination—when the plan denies PA, reduces payment, rescinds coverage, or says care is not medically necessary or not a covered benefit.
Every insurer issuing a Wisconsin health benefit plan must maintain an OCI-approved internal grievance procedure under Wis. Stat. § 632.83. You must generally complete grievance before independent review under § 632.835.
General walkthrough: Appeals roadmap.
Wisconsin appeal timelines
Internal grievance (§ 632.83)
Wisconsin's grievance procedure must include:
- Written grievance submission in any form
- A grievance panel with at least one person authorized to take corrective action and at least one insured member (when available)
- Prompt investigation
- Written notice of disposition and any corrective action
OCI publication: Health insurance grievances (PI-217).
Federal internal appeal standards (many ACA and group plans)
For many Wisconsin-regulated health benefit plans, federal standards also apply:
- File within 180 days of the adverse benefit determination in most cases
- Pre-service appeals: decision within 30 days
- Post-service appeals: within 60 days
- Urgent appeals: as fast as the medical condition requires, often within 72 hours
Bypass grievance for independent review
You may skip internal grievance if you and the insurer agree, or if the selected IRO determines that requiring grievance first would jeopardize life, health, or ability to regain maximum function (§ 632.835(2)(d)).
How to file
- Read the denial for grievance instructions and deadlines.
- Tell your insurer you want to file a grievance (use the process on your notice).
- Submit in writing with member ID, clinical support, and any records your doctor provides.
- Request expedited review if delay would seriously jeopardize life or health.
- Keep copies of everything sent and the date sent.
Carrier links: Wisconsin prior auth & internal appeals links.
Evidence that helps
- Treating clinician letter on medical necessity
- Insurer's clinical criteria (request in writing if not provided)
- Peer-reviewed literature for experimental/investigational disputes
Medicaid appeals
BadgerCare Plus / ForwardHealth managed care uses a separate MCO grievance and fair hearing process:
- MCO internal appeal: typically within 60 days of the adverse benefit determination notice
- State fair hearing: after exhausting the MCO process, request within 90 days of the MCO decision (DHS fair hearing form (F-00236)) · Division of Hearings and Appeals, P.O. Box 7875, Madison, WI 53707-7875
- Help: Medicaid Managed Care Ombudsman 800-760-0001
After internal appeal
If you receive a final grievance denial with independent review rights, request review within 4 months (OCI — independent review (PI-203)).