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Independent Review Organizations Certified to
Perform Independent Reviews in Wisconsin
Wisconsin's independent review process may help you resolve some disputes with your health plan regarding its coverage denial. This process allows you to have a medical expert with no connection to your health plan review the health plan's decision. In most cases, you will first be required to complete your health plan's internal grievance process. If your health plan's internal grievance process results in an adverse determination, you may choose an Independent Review Organization (IRO) from the list below and send your request for an independent review to your health plan.
An independent review is available whenever your health plan denies you coverage because it maintains that the treatment is not medically necessary or appropriate or that the treatment is experimental or investigational. All of the IROs listed below perform these types of reviews in Wisconsin.
You may also request an independent review if your health plan denies coverage based on a preexisting condition exclusion or if it rescinds your health insurance policy or certificate. Please note that Maximus is the only IRO currently certified to perform reviews of preexisting condition exclusion denials or rescissions.
The Fact Sheet on the Independent Review Process in Wisconsin provides more information about this process. It can be found at http://oci.wi.gov/pub_list/pi-203.htm. You can also contact OCI at the address on the How to Contact Us page to request a copy.
A copy of the listing of organizations certified is available in p d f format for printing at: http://oci.wi.gov/iroscert.pdf (opens in new window). Note: You will need an Adobe Acrobat Reader to view or print pdf version, which you can download at no cost from Adobe .
The following organizations, listed in alphabetical order, have been certified as IROs in Wisconsin:
| Name/Address | Phone/Fax | Types of Reviews | Comments |
|---|---|---|---|
| IPRO 1979 Marcus Ave. Lake Success, NY 11042-1002 www.ipro.org |
800-227-3143 516-304-3760 (fax) |
Limits reviews to medical necessity or appropriate denials and to experimental treatment denials All medical specialties available |
Certified 5/19/03 Contact: |
| MAXIMUS - Center for Health Dispute Resolution Eastgate Square 50 Square Dr Ste 210 Victor, NY 14564-1099 www.healthappeal.com |
866-763-6395 585-425-5296 (fax) |
Comprehensive - provides all types of eligible reviews All medical specialties available |
Certified 10/01/02 Contact: |
| MCMC LLC 300 Crown Colony Dr. Ste. 203 Quincy, MA 02169 www.mcmcllc.com |
888-313-6267 301-652-1250 (fax) |
Limits reviews to medical necessity or appropriate denials and to experimental treatment denials All medical specialties available |
Certified 9/8/06 Gabrielle Susi or Amber Tharp 301-652-1818 |
| Medical Consultants Network, Inc. 901 Boren Ave. Ste. 1400 Seattle, WA 98104 www.mcn.com |
800-636-3926 206-623-4956 (fax) |
Limits reviews to medical necessity or appropriate denials and to experimental treatment denials All medical specialties available |
Certified 7/15/11 Erik Halse, ext. 2206 |
| Medical Review Institute of America 2875 S. Decker Lake Dr. Ste. 550 PO Box 25547 Salt Lake City, UT 84125-0547 www.mrioa.com |
800-654-2422 801-261-3189 (fax) |
Limits reviews to medical necessity or appropriate denials and to experimental treatment denials All medical specialties available |
Certified 3/29/02 Laura Daley, ext. 415 |
| National Medical Reviews, Inc. 260 Knowles Ave. Ste. 330 Southampton, PA 18966 www.nmrusa.com |
800-283-8196 215-352-7801 (fax) |
Limits reviews to medical necessity or appropriate denials and to experimental treatment denials All medical specialties available |
Certified 7/20/09 Elaine Nace, Esq., ext. 106 |
| Permedion 350 Worthington Rd. Ste. H Westerville, OH 43082-8325 www.permedion.com |
800-473-0802 614-895-6784 (fax) |
Limits reviews to medical necessity or appropriate denials and to experimental treatment denials All medical specialties available |
Certified 3/29/02 Sue Butterfield, ext. 3428 |
| Prest & Associates 2712 Marshall Court Ste. 1 Madison, WI 53705 www.prestmds.com |
800-358-5129 608-232-9929 (fax) |
Limits reviews to medical necessity or appropriate denials and to experimental treatment denials Limited to: Psychiatry, Behavioral Health & Addictions Medicine |
Certified 5/19/03 Susan Prest or Jay Story |
Your health plan should provide you with information on your right to request an independent review in its written materials. You can also call the health plan at its toll-free number and request information on independent review.
Independent Review Annual Reports
Independent Review Process Minimum Adjusted Dollar Amount
Further questions may be directed to: ocihmo@wisconsin.gov