WI AB1128

Creates the Office of the Public Intervenor attached to the Office of the Commissioner of Insurance to assist individuals with health insurance claims, appeals, and legal actions related to coverage for medical procedures, prescription medications, and other health care services

Requires health insurers to process claims within reasonable timeframes, provide detailed explanations for denials citing specific medical or policy bases, and disclose when artificial intelligence or algorithmic decision-making is used in claims processing

Prohibits insurers from using vague terms to deny claims, allowing non-physicians to determine medical necessity, requiring patients to fail cheaper treatments before approving necessary care (step therapy), and applying stricter standards for mental health claims than physical health claims

Mandates insurers publish annual reports beginning January 1, 2027 detailing claim denial rates, reasons for denials, appeal outcomes, and AI usage statistics including denial rate comparisons between AI and human reviewers

Authorizes the Commissioner of Insurance to audit insurers with high-frequency claim denials and impose $10,000 per occurrence civil forfeitures for violations that result in harmful care delays or adverse health outcomes