632.875 Independent evaluations relating to chiropractic treatment.

(1) In this section:

(a) “Chiropractor" means a person licensed to practice chiropractic under ch. 446.

(b) “Independent evaluation" means an examination or evaluation by or recommendation of a chiropractor or a peer review committee under s. 632.87 (3) (b) 1.

(c) “Patient" means a person whose treatment by a chiropractor is the subject of an independent evaluation.

(d) “Treating chiropractor" means a chiropractor who is treating a patient and whose treatment of the patient is the subject of an independent evaluation.

(2) If, on the basis of an independent evaluation, an insurer restricts or terminates a patient's coverage for the treatment of a condition or complaint by a chiropractor acting within the scope of his or her license and the restriction or termination of coverage results in the patient becoming liable for payment for his or her treatment, the insurer shall, within the time required under s. 628.46 (2m), provide to the patient and to the treating chiropractor a written statement that contains all of the following:

(a) A statement that an independent evaluation has been conducted under s. 632.87 (3) (b) 1.

(b) The name of the treating chiropractor.

(c) The name of the patient.

(d) A description of the insurer's internal appeal process that is available to the patient.

(e) A statement indicating that the patient may, no later than 30 days after receiving the statement required under this subsection, request an internal appeal of the insurer's restriction or termination of coverage.

(f) The address to which the patient should send the request for an appeal.

(g) A detailed explanation of the clinical rationale and of the basis in the policy, plan, or contract or in applicable law for the insurer's restriction or termination of coverage.

(h) A list of records and documents reviewed as part of the independent evaluation.

(3)

(a) In this subsection, “claim" means a patient's claim for coverage, under a policy, plan or contract covering diagnosis and treatment of a condition or complaint by a licensed chiropractor within the scope of the chiropractor's professional license, the restriction or termination of which coverage is the subject of an independent evaluation.

(b) A chiropractor who conducts an independent evaluation may not be compensated by an insurer based on a percentage of the dollar amount by which a claim is reduced as a result of the independent evaluation.

(4) Subject to sub. (2) (e), an insurer shall make available to a patient an internal procedure by which the patient may appeal an insurer's decision to restrict or terminate coverage.

(5) This section does not apply to any of the following:

(a) Worker's compensation insurance.

(b) Any line of property and casualty insurance except disability insurance. In this paragraph, “disability insurance" does not include uninsured motorist coverage, underinsured motorist coverage or medical payment coverage.

History: 1995 a. 94; 2001 a. 16; 2007 a. 20.