State guide

Wisconsin

Pick the kind of plan you have to see who to call first. Wisconsin can only help with plans it regulates.

On this page 8

Which plan do you have?
Quick facts for independent review
Who regulates health plans
Independent (external) review
Free help in Wisconsin
Medicare and Medicaid in Wisconsin
State laws that can help
Sources and what we could not confirm

Which plan do you have? Who to call first, by coverage

Your employer pays claims itself

Wisconsin usually cannot help with these plans. Call the Employee Benefits Security Administration.

Call 1-866-444-3272
Insurance you buy, or an employer plan bought from an insurer

Call Wisconsin Office of the Commissioner of Insurance (OCI). See the at-a-glance box.

Call 800-236-8517
Medicaid or children's coverage

Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Wisconsin.

Medicaid in Wisconsin
Medicare

Wisconsin State Health Insurance Assistance Program (SHIP), including the Medigap Helpline run by the Board on Aging and Long Term Care gives free counseling. Or call 1-800-MEDICARE.

Call 1-800-242-1060 1-800-633-4227

The short version for Wisconsin

Wisconsin's Office of the Commissioner of Insurance (OCI) takes complaints about insurers and publishes plain guides to the grievance and independent review process. Independent review is free, you ask your insurer (not the state) for it within four months, and the insurer pays the reviewer. Wisconsin has no federal-style Consumer Assistance Program, and its one dedicated nonprofit health-law clinic has paused new clients, so Medicare and Medicaid members have the most structured free help. The federal government's list shows Wisconsin plans using the federal (Department of Health and Human Services) review process, while the state's own guides describe a state process, so check your denial letter for which one applies.

At a glance: independent review for plans Wisconsin regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator: Wisconsin Office of the Commissioner of Insurance (OCI) · 800-236-8517 (toll free); 608-266-0103 (local)
Independent review: A state process for some plans and the federal process for others (Independent review (state process, run through an independent review organization); plans using the federal process call it external review)
Deadline to request it: 4 months (120 days) after the date of the insurer's grievance decision
Cost: None. The insurer pays the independent review organization's fees.
Decision time: Up to 30 business days once the reviewer has the file (the insurer has 5 business days to send records and the reviewer has 5 business days to ask for more); fast track: 72 hours after the review request is received

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Wisconsin Office of the Commissioner of Insurance (OCI)
Health insurance sold by insurance companies in Wisconsin (individual plans and fully insured employer plans). It does not handle Medicare, Medicaid, other federal plans, or employer self-funded plans, which follow federal law.

Phone: 800-236-8517 (toll free); 608-266-0103 (local). File a complaint online

Independent (external) review

Process: A state process for some plans and the federal process for others. Run by Independent review organizations certified by the Office of the Commissioner of Insurance (state process); for plans using the federal process, the U.S. Department of Health and Human Services contractor or the insurer's own accredited review organizations.
Where you file: insurer
How: Your insurer's final written decision on your grievance should explain how to ask for independent review. Send a written request to the address in that letter with your name, address and phone number, why you think the treatment should be covered, supporting records or a doctor's letter, and a signed authorization if someone files for you. If your plan uses the federal process, the state guide says to go through externalappeal.cms.gov or call 1-888-866-6205, ext. 3326.
Which denials qualify: Denials a plan bases on medical judgment: not medically necessary, experimental, out-of-network services you need for the provider's clinical expertise, denial based on a preexisting condition exclusion, or a retroactive cancellation (rescission) of your coverage. The treatment must be a covered benefit; benefit exclusions and administrative disputes (such as late premiums) do not qualify.
Appeal to the plan first?: Yes in most cases. Exceptions: you and the insurer both agree to skip the grievance, or you need immediate care and a delay could jeopardize your life or health (send the expedited independent review request at the same time as the expedited grievance; the review organization decides whether to allow it).

Official page

General rules and what to send: how external review works, how to request it.

Free help in Wisconsin

Office of the Commissioner of Insurance, complaints
Sends your complaint to the insurer, requires a response, and checks whether the insurer followed Wisconsin law and your policy; for state-regulated health plans only. The federal directory states Wisconsin has no Consumer Assistance Program.

Phone: 800-236-8517
Wisconsin Board on Aging and Long Term Care, Long Term Care Ombudsman Program
Free advocacy for people age 60 and older in nursing homes and assisted living, and for people in the state's managed long-term care programs (Family Care, Partnership, PACE, IRIS), including appeals of denied long-term care services.

Phone: 1-800-815-0015
Legal Action of Wisconsin
Free civil legal help for low-income people, including public benefits appeals such as Medicaid (BadgerCare Plus); the phone number is as printed on ABC for Health's referral notice.

Phone: 855-947-2529

Medicare and Medicaid in Wisconsin

Medicare counseling: Wisconsin State Health Insurance Assistance Program (SHIP), including the Medigap Helpline run by the Board on Aging and Long Term Care · 1-800-242-1060 (Medigap Helpline); 1-855-677-2783 (Medigap Part D and prescription drug helpline) . Free help with Medicare appeals.
Medicaid agency: Wisconsin Department of Health Services, Medicaid and BadgerCare Plus (ForwardHealth)
Fair hearing deadline: Fee-for-service Medicaid and BadgerCare Plus: request a fair hearing within 45 days of the date the action takes effect. Managed care (HMO) plan denials: appeal to the plan within 60 days of the notice, then request a fair hearing within 90 days of the plan's decision on your appeal. Your notice states the deadline that applies to you.
Good to know: Fair hearings are run by the Department of Administration, Division of Hearings and Appeals (PO Box 7875, Madison, WI 53707-7875; 608-266-7709). To keep benefits going while you appeal, ask for the hearing before the action's effective date; you may have to repay them if you lose. The HMO deadlines (60 and 90 days) come from the Department of Health Services' HMO grievance and appeals guide and a plan member handbook; the hearing-information form itself states only the 45-day rule. Member services: 800-362-3002 (per the federal directory).

Medicaid appeals page How Medicaid appeals work

State laws that can help

Step therapy. If a plan uses step therapy it must offer a clear exception process and must grant an exception when the required drug is contraindicated, expected to be ineffective, already failed, or you are stable on your current drug; the plan has 3 business days to decide (next business day if urgent) and a request not answered in time is considered granted.

Wis. Stat. § 632.867 (2019 Wisconsin Act 12)
External review. Wisconsin requires an independent external review procedure for denials the plan bases on medical necessity, experimental treatment, or rescission, overseen by the Office of the Commissioner of Insurance.

Wis. Adm. Code § INS 18.11
Prior authorization. A plan may not require prior authorization for emergency services needed to evaluate or stabilize an emergency medical condition, and must decide a prior authorization request for an experimental procedure within 5 working days of a complete request.

Wis. Stat. §§ 632.85 and 632.855

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on 2026-11-11. Phone numbers and deadlines change; check the official page before you rely on one.

Not confirmed (8)

Which independent review process applies. CMS's state list puts Wisconsin in the HHS-administered federal column, but OCI's own consumer fact sheet (updated January 2025) describes a state independent review process and its grievance guide says most plans follow the federal process. Both are described in the record; the denial letter should say which applies.
The independent review request form. OCI publishes no consumer request form; the request goes to the insurer's address.
Not confirmed. externalReview.decisionsDatabaseUrl and statistics — no public decisions database or official overturn rate was found.
The state regulators. OCI pages disagree on which of 800-236-8517 and 608-266-0103 is the in-state line (its complaint form PDF reverses them); CMS's federal directory lists 800-236-8517 as toll free and 608-266-0103 as local.
Not confirmed. medicaid.fairHearingDeadline (HMO 60/90 days) — taken from the Department of Health Services HMO guide and a plan handbook, not a consumer-facing state page; the BadgerCare Plus/Medicaid ombuds number (1-800-760-0001) appeared only in a plan handbook and is omitted.
Not confirmed. consumerAssistance (Legal Action of Wisconsin) — the Legal Action of Wisconsin website and phone were not opened; the number comes from ABC for Health's referral notice and the website from a Department of Health Services form.
Not confirmed. stateLaws (external-review) — cited from the Employee Trust Funds page quoting Wis. Adm. Code INS 18.11; the code text itself was not read.
Not confirmed. No Wisconsin prior authorization timelines law or gold card law exists: the 2025 bills (AB 432, AB 1217) failed to pass; a third-party site claiming a Wis. Stat. 632.861 timeline was not relied on.

Sources last checked 11 November 2026. Found a mistake? Report it.