How to appeal a health insurance denial in Wisconsin
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Depending on your plan, external review in Wisconsin runs through the state’s process or the federal one; your final denial letter says which. The deadline to ask: within four months (120 days) of the date the grievance decision was provided to you.
Does this apply to you? State external review covers plans regulated by Wisconsin: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Wisconsin
Within four months (120 days) of the date the grievance decision was provided to you
If waiting could jeopardize your life or health, the IRO must decide no later than 72 hours after receiving the request. Send the expedited independent review request at the same time as your expedited grievance to the insurer, and the IRO decides whether you can skip the internal grievance.
Free
State-regulated plans (insurance bought in Wisconsin or through an employer that buys insurance). Self-funded employer plans use the federal process. Medicare, Medicaid and other federal plans have their own appeals.
OCI says most Wisconsin plans must follow the federal external review process. Under it, the insurer either uses the HHS process run by MAXIMUS (externalappeal.cms.gov, 888-866-6205 ext. 3326) or contracts with at least three accredited IROs. Wisconsin's own independent review (s. 632.835, OCI-certified IROs) covers plans outside the ACA rules. Either way, send your request to the address in the insurer's final grievance decision, not to OCI; that letter says which process applies. The 800 number is the statewide line; in Madison call 608-266-0103.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Wisconsin?
Within four months (120 days) of the date the grievance decision was provided to you
Can I get a fast external review in Wisconsin?
If waiting could jeopardize your life or health, the IRO must decide no later than 72 hours after receiving the request. Send the expedited independent review request at the same time as your expedited grievance to the insurer, and the IRO decides whether you can skip the internal grievance.
Does external review cost anything in Wisconsin?
Free
Do Wisconsin’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- Wisconsin OCI: Independent Review Process in Wisconsin
Send your written request for independent review to the address provided in the company's final written decision within four months (120 days) of the date the grievance decision was provided to you.
- Wisconsin OCI: Health Insurance Grievances and Complaints (PI-217)
Most health plans in Wisconsin are required to follow the federal external review process.
- Wis. Stat. § 632.835
within 4 months after the insured receives notice of the disposition of his or her grievance
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.