Ins 3.65(3)(a)9.
9. A social worker, marriage and family therapist or professional counselor certified under ch.
457, Stats.
Ins 3.65(3)(a)11.
11. A corporation of any providers specified under subds.
1. to
9. that provides health care services.
Ins 3.65(3)(a)12.
12. An operational cooperative sickness care plan organized under ss.
185.981 to
185.985, Stats., that directly provides services through salaried employees in its own facility.
Ins 3.65(3)(b)
(b) Coding requirements. In addition to HCFA's coding instructions, the following restrictions and conditions apply to the use of the HCFA-1500 form:
Ins 3.65(3)(b)1.
1. The only coding systems an insurer may require a health care provider to use are the following:
Ins 3.65(3)(b)2.
2. For anesthesia services for which there is no applicable HCPCS level 1 anesthesia code, a health care provider shall use the applicable HCPCS level 1 surgery code.
Ins 3.65(3)(b)3.
3. An insurer may not require a health care provider to use any other verbal descriptor with a code or to furnish additional information with the initial submission of a HCFA-1500 form except under the following circumstances:
Ins 3.65(3)(b)3.a.
a. When the procedure code used describes a treatment or service which is not otherwise classified.
Ins 3.65(3)(b)3.b.
b. When the procedure code is followed by the CPT-4 modifier 22, 52 or 99. A health care provider using the modifier 99 may use item 19 of the HCFA-1500 form to explain the multiple modifiers.
Ins 3.65(3)(b)3.c.
c. When required by a contract between the insurer and health care provider.
Ins 3.65(3)(b)4.
4. A health care provider may use item 19 of the HCFA-1500 form to indicate that the form is an amended version of a form previously submitted to the same insurer by inserting the word “amended" in the space provided.
Ins 3.65(3)(c)
(c) Use of unique identifiers. In completing the HCFA-1500 form, the individual or entity filing the claim shall do all of the following:
Ins 3.65(3)(c)1.
1. In item 17a, use the unique physician identifier number assigned by HCFA or, if the physician does not have such a number, the physician's taxpayer identification number assigned by the U. S. internal revenue service.
Ins 3.65(3)(c)2.b.
b. The unique physician identifier number assigned by HCFA to the individual health care provider who performed the procedure or ordered the service or, if the individual does not have such a number, the individual's taxpayer identification number assigned by the U. S. internal revenue service.
Ins 3.65(4)(a)(a) Required users; instructions. For providing a health insurance claim form directly to a patient or filing a claim on behalf of a patient, all of the following health care providers shall use the format of the HCFA-1450 form, following the instructions for use in the Wisconsin uniform billing manual:
Ins 3.65(4)(b)
(b) Coding requirements. The only coding systems an insurer may require a health care provider to use are the following:
Ins 3.65(4)(b)3.
3. If charges for professional health care provider services are included, HCPCS or DSM-III-R codes.
Ins 3.65(4)(c)
(c) Claims for outpatient services; supplemental form permitted. A hospital may use a HCFA-1500 form to supplement a HCFA-1450 form if necessary to complete a claim for outpatient services.
Ins 3.65(5)(a)
(a) Required users; instructions. For providing a health insurance claim form directly to a patient or filing a claim with an insurer on behalf of a patient, a dentist or a corporation or partnership of dentists shall use the format of the ADA dental claim form, following the instructions for use in the American dental association CDT-1 user's manual.
Ins 3.65(5)(b)
(b) Coding. An insurer may not require a dentist to use any code other than the following:
Ins 3.65(6)(b)
(b) Filing claims. A health care provider may file a claim with an insurer using either a paper form or electronic transmission. If a health care provider does not file a claim on behalf of a patient, the health care provider shall provide the patient with the same form that would have been used if the provider had filed a claim on behalf of the patient.
Ins 3.65(6)(c)1.1. If the information conveyed by standard coding is insufficient to enable an insurer to determine eligibility for payment, the insurer may require a health care provider to furnish additional medical records to determine medical necessity or the nature of the procedure or service provided.
Ins 3.65(6)(c)2.
2. The 30-day period allowed for payment of a claim under s.
628.46 (1), Stats., begins when the insurer has sufficient information to determine eligibility for payment.
Ins 3.65(6)(d)
(d) Use of current forms and codes. In complying with this section, a health care provider shall do all of the following that are applicable:
Ins 3.65(6)(d)1.
1. Use the most current version of the HCFA-1500 or HCFA-1450 claim form and accompanying instructions by the mandatory effective date HCFA specifies for use in filing medicare claims.
Ins 3.65(6)(d)2.
2. Begin using modifications to a required coding system for all billing and claim forms by the mandatory effective date HCFA specifies for use in filing medicare claims.
Ins 3.65 History
History: Cr.
Register, August, 1993, No. 452, eff. 9-1-93; am. (6) (b),
Register, February, 1994, No. 458, eff. 3-1-94; corrections in (4) (a) 2. and 3. made under s. 13.93 (2m) (b) 7., Stats.,
Register, July, 1999, No. 523; correction in (4) (a) 1. made under s. 13.92 (4) (b) 7., Stats.,
Register March 2017 No. 735.
Ins 3.651
Ins 3.651 Standardized explanation of benefits and remittance advice format. Ins 3.651(1)(1)
Purpose. This section implements s.
632.725 (2) (c), Stats., by prescribing the requirements for the following, to be used by insurers providing health care coverage to one or more residents of this state:
Ins 3.651(1)(a)
(a) Remittance advice forms that insurers furnish to health care providers.
Ins 3.651(1)(b)
(b) Explanation of benefits forms that insurers furnish to insureds.
Ins 3.651(2)
(2)
Definitions. In addition to the definitions in s.
Ins 3.65, in this section, “claim adjustment reason codes" means the claim disposition codes of the American national standards institute accredited standards committee X12 (ASC X12).
Ins 3.651 Note
Note:
The claim adjustment reason codes referenced in subsections (2), (3) (b) 4. i., (4) (a) 5. f. and (5), form OCI 17-007, may be obtained from the Office of the Commissioner of Insurance, P. O. Box 7873, Madison, Wisconsin 53707-7873 or on the Office of the Commissioner of Insurance website at
http://oci.wi.gov/.
Ins 3.651(3)
(3)
Remittance advice to health care providers. Ins 3.651(3)(a)1.1. With each payment to a health care provider, an insurer shall provide a remittance advice form conforming to the format specified in Appendix A, except as provided in subd.
2. and par.
(d).
Ins 3.651(3)(a)2.
2. The remittance advice form of an insurer with less than $50,000 in annual premiums for health insurance sold in this state, as reported in its most recent annual statement, is not required to conform to the format specified in Appendix A but, with each payment to a health care provider, the insurer shall provide a remittance advice form which includes all of the applicable information specified in par.
(b).
Ins 3.651(3)(b)
(b) Information required. The remittance advice form shall include, at a minimum, all of the following information:
Ins 3.651(3)(b)1.
1. The insurer's name and address and the telephone number of a section of the insurer designated to handle questions and appeals from health care providers.
Ins 3.651(3)(b)2.
2. The insured's name and policy number, certificate number or both.
Ins 3.651(3)(b)3.
3. The last name followed by the first name and middle initial of each patient for whom the claim is being paid, the patient identification number and the patient account number, if it has been supplied by the health care provider.
Ins 3.651(3)(b)4.i.
i. Each claim adjustment reason code, unless the claim is adjusted solely because of a deductible, copayment or coinsurance or a combination of any of them.
Ins 3.651(3)(c)1.1. If an insurer includes claims for more than one policyholder or certificate holder on the same remittance advice form, all claims for the same policyholder or certificate holder shall be grouped together.
Ins 3.651(3)(c)2.
2. If an insurer includes claims for more than one patient on the same remittance advice form, all claims for the same patient shall be grouped together.
Ins 3.651(3)(d)1.
1. An insurer may print its remittance advice form in either horizontal or vertical format.
Ins 3.651(3)(d)2.
2. A remittance advice form need not include a column for any item specified in par.
(b) 4. which is not applicable, but the order of the columns that are included may not vary from the order shown in Appendix A, except as provided in subd.
3. Ins 3.651(3)(d)3.
3. A remittance advice form may provide additional information about claims by including one or more columns not shown in Appendix A immediately before the column designated for the claim adjustment reason code.
Ins 3.651(3)(d)4.
4. An insurer may alter the wording of a column heading shown in Appendix A provided the meaning remains the same.
Ins 3.651(3)(d)5.
5. If necessary for clarity when claims for more than one insured or more than one patient are included on the same form, an insurer shall vary the location of the information specified in par.
(b) 2. and
3. to ensure that it appears with the claim information to which it applies.
Ins 3.651(3)(e)
(e) An insurer shall send the remittance advice form to the payee designated on the claim form.
Ins 3.651 Note
Note:
If, on March 1, 1994, an insurer has a contract with a health care provider that governs the form and content of remittance advice forms, s.
Ins 3.651 (3), as affected March 1, 1994, first applies to the insurer on the date the contract is renewed, but no later than December 31, 1994.
Ins 3.651(4)(a)
(a) The explanation of benefits form for insureds shall include, at a minimum, all of the following:
Ins 3.651(4)(a)1.
1. The insurer's name and address and the telephone number of the section of the insurer designated to handle questions and appeals from insureds relating to payments.
Ins 3.651(4)(a)2.
2. The insured's name, address and policy number, certificate number or both.
Ins 3.651(4)(a)3.
3. A statement as to whether payment accompanies the form, payment has been made to the health care provider or payment has been denied.
Ins 3.651(4)(a)4.
4. The last name followed by the first name and middle initial of each patient insured under the policy or certificate for whom claim information is being reported, and the patient account number, if it has been supplied by the health care provider.
Ins 3.651(4)(a)5.
5. For each patient listed, all of the following that are applicable, using a single line for each procedure or service:
