New to helping someone in Wisconsin?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan (Anthem, UnitedHealthcare, Quartz, Dean, and others).
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (HealthCare.gov, job-based, BadgerCare/Medicaid, Medicare) and write down the appeal deadline from the letter.
For many Wisconsin-regulated plans, you have an internal grievance with the insurer first, then a right to independent review through an OCI-certified IRO you select under Wis. Stat. § 632.835.
For steps that work in every state, read these general guides first, then return here for Wisconsin rules:
What is different in Wisconsin?
- HealthCare.gov: Wisconsin uses the federal Marketplace at HealthCare.gov. Major 2026 carriers include Anthem/Blue Cross Blue Shield, UnitedHealthcare, Quartz, Dean/SSM Health Plan, Network Health, Security Health Plan, CareSource (Common Ground), and others (availability varies by county). Free help: WisCovered.com.
- Prior authorization: § 632.85 (no PA for emergency care); § 632.855 (5 working days for experimental treatment PA); federal CMS timing (7-day / 72-hour) for many plans in 2026.
- Internal appeals: § 632.83 grievance panel process; federal standards often apply—180 days to file.
- Independent review: You choose an OCI-certified IRO—file within 4 months of grievance resolution; 30 business days standard / 72 hours expedited; binding on insurer (free to you).
- BadgerCare / Medicaid: MCO appeal first, then Division of Hearings and Appeals fair hearing—often 90 days—not commercial IRO review.
Who is in charge of your plan?
- OCI (Office of the Commissioner of Insurance): Independent review, regulated commercial plans — Independent review (PI-203). 800-236-8517
- U.S. Department of Labor / HHS: Many self-funded ERISA plans.
- DHS / ForwardHealth: BadgerCare and Medicaid managed care — ForwardHealth · Medicaid Ombudsman 800-760-0001
- CMS / SHIP: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.