Utilization Review Licensing in Wisconsin

Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Wisconsin. For assistance with licensing, please contact us to learn about our software and managed license services.

Wisconsin Independent Review Organization Certification

Type of Review:

Medical Utilization Review

Agency:Wisconsin Office of the Commissioner of Insurance

WI Stat. § 632.835(4)

Fact Checked:2/18/21

Initial Registration


Application for Certification

Agency Fee:


Required Attachments:
  • Conflict of Interest Statement
  • Certification of Impartiality of MarketingPractices
  • Biographical sketches for all directors, officers, executives, owners, and the medical director
  • Additional attachments as laid out in the application
Fact Checked:2/18/21

Registration Renewal


Application for Recertification

Agency Fee:




Fact Checked:2/18/21

Registration Not Required

Not required

Supplemental Reporting
Independent Review Annual Report


Independent Review Organization Annual Report Form

Agency Fee:



Annually by March 1.


Wisconsin Admin Code Ins. 18.16

Fact Checked:2/19/21

Wisconsin Resources

Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

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