Ins 3.54(4)(b)
(b) An insurer shall review each home care claim under a disability insurance policy and may not deny coverage of a home care claim based solely on Medicare's denial of benefits.
Ins 3.54(4)(c)
(c) An insurer may deny coverage of all or a portion of a home health aide service visit because the visit is not medically necessary, not appropriately included in the home care plan or not necessary to prevent or postpone confinement in a hospital or skilled nursing facility only if:
Ins 3.54(4)(c)1.
1. The insurer has a reasonable, and documented factual basis for the determination; and
Ins 3.54(4)(c)2.
2. The basis for the determination is communicated to the insured in writing.
Ins 3.54(4)(d)
(d) In determining whether a home care claim, including a claim for home health aide services, is reimbursable under a disability insurance policy, an insurer may apply claim review criteria to determine that home is an appropriate treatment setting for the patient and that it is not reasonable to expect the patient to obtain medically necessary services or supplies on an outpatient basis, subject to the requirements of s.
632.895 (2) (g), Stats.
Ins 3.54(4)(e)
(e) An insurer shall disclose and clearly define the home care benefits and limitations in a disability insurance policy, certificate and outline of coverage. An insurer may not use the terms “homebound" or “custodial" in the sections of a policy describing home care benefits, exclusions, limitations, or reductions.
Ins 3.54(4)(f)
(f) In determining whether a home care claim under a disability insurance policy involves medically necessary part-time or intermittent care, an insurer shall give due consideration to the circumstances of each claimant and may not make arbitrary decisions concerning the number of home care visits within a given period which the insurer will reimburse. An insurer may not deny a claim for home care visits without properly reviewing and giving due consideration to the plan of care established by the attending physician under s.
632.895 (1) (b), Stats. An insurer may use claim review criteria based on the number of home care visits in a period for the purpose of determining whether a more thorough review of a home care claim or plan is conducted.
Ins 3.54(4)(g)
(g) An insurer may use claim review criteria under par.
(d) or
(f) only if the criteria and review process do not violate s.
Ins 6.11. An insurer shall comply with s.
628.34 (1), Stats., when communicating claim review criteria to applicants, insureds, providers or the public.
Ins 3.54 History
History: Cr.
Register, April, 1976, No. 376, eff. 6-1-87.
Ins 3.55
Ins 3.55
Benefit appeals under long-term care policies, life insurance-long-term care coverage. Ins 3.55(1)(1)
Purpose. This section implements and interprets s.
632.84, Stats., for the purpose of establishing minimum requirements for the internal procedure for benefit appeals that insurers shall provide in long-term care policies, life insurance-long-term care coverage. This section also facilitates the review by the commissioner of these policy forms.
Ins 3.55(2)
(2)
Scope. This section applies to individual and group nursing home insurance policies issued or renewed on or after August 1, 1988, and to long-term care policies and life insurance-long-term care coverage issued or renewed on and after June 1, 1991, except for polices or coverage exempt under s.
Ins 3.455 (2) (b). This section does not apply to health maintenance organizations, limited service health organization or preferred provider plan, as those are defined in s.
609.01, Stats.
Ins 3.55(3)(a)
(a) “Benefit appeal" means a request for further consideration of actions involving the denial of a benefit.
Ins 3.55(3)(b)
(b) “Denial of a benefit" means any denial of a claim, the application of a limitation or exclusion provision, and any refusal to continue coverage.
Ins 3.55(3)(c)
(c) “Internal procedure" means the insurer's written procedure for handling benefit appeals.
Ins 3.55(4)(a)(a) Pursuant to s.
632.84 (2), Stats., an insurer shall include an internal procedure for benefit appeals in any long-term care policy or life insurance-long-term care coverage.
Ins 3.55(4)(b)
(b) The insurer shall provide the policyholder and insured with a written description of the benefit appeals internal procedure at the time the insurer gives notice of the denial of a benefit. The written description shall include the name, address, and phone number of the individual designated by the insurer to be responsible for administering the benefit appeals internal procedure.
Ins 3.55(4)(c)
(c) An insurer shall describe the benefit appeals internal procedure in every policy, group certificate, and outline of coverage. The description shall include a statement on the following:
Ins 3.55(4)(c)1.
1. The insured's right to submit a written request in any form, including supporting material, for review by the insurer of the denial of a benefit under the policy; and
Ins 3.55(4)(c)2.
2. The insured's right to receive notification of the disposition of the review within 30 days of the insurer's receipt of the benefit appeal.
Ins 3.55(4)(d)
(d) An insurer shall retain records pertaining to a benefit appeal filed and the disposition of this appeal for at least 3 years from the date that the insurer files with the commissioner under sub.
(5) the annual report in which information concerning the appeal is reported.
Ins 3.55(4)(e)
(e) No insurer may impose a time limit for filing a benefit appeal that is less than 3 years from the date the insurer gives notice of the denial of a benefit.
Ins 3.55(4)(f)
(f) An insurer shall make any internal procedure established pursuant to s.
632.84, Stats., available to the commissioner upon request and in as much detail as the commissioner requests.
Ins 3.55(5)
(5)
Reports to the commissioner. An insurer offering a long-term care insurance policy or rider shall report to the commissioner by March 31 of each year a summary of all benefit appeals filed during the previous calendar year and the disposition of these appeals, including:
Ins 3.55(5)(a)
(a) The name of the individual designated by the insurer to be responsible for administering the benefit appeals internal procedure;
Ins 3.55(5)(b)
(b) Changes made in the administration of claims as a result of the review of benefit appeals;
Ins 3.55(5)(d)
(d) The date each benefit appeal was filed and, if within the calendar year, subsequently resolved;
Ins 3.55(5)(e)
(e) The date each benefit appeal carried over from the previous calendar year was resolved;
Ins 3.55(6)
(6)
Policy disapproval. The commissioner shall disapprove a policy under s.
631.20, Stats., if that policy does not meet the minimum requirements specified in this section.
Ins 3.55 History
History: Cr.
Register, May, 1989, No. 401, eff. 1-1-90; am. (1), (2) and (4) (a), r. (3) (f), cr. (3) (cg) and (cm),
Register, April, 1991, No. 424, eff. 6-1-91;
EmR0817: emerg. am. (3) (cg) and (cm), eff. 6-3-08;
CR 08-032: am. (3) (cg) and (cm)
Register October 2008 No. 634, eff. 11-1-08;
CR 19-036: am. (title), (1), (2), r. (3) (d), (e), am. (4) (a), (5) (intro.)
Register December 2019 No. 768, eff. 1-1-20.
Ins 3.55 Note
Note:
CR 08-032 first applies to policies or certificates issued on or after January 1, 2009 or on the first renewal date on or after January 1, 2009, but no later than January 1, 2010 for collectively bargained policies or certificates.
Ins 3.60
Ins 3.60
Disclosure of information on health care claim settlements. Ins 3.60(1)(1)
Purpose. This section implements and interprets s.
628.34 (1) (a) and
(12), Stats., for the purpose of allowing insureds and providers access to information on the methodology health insurers use to determine the eligible amount of a health insurance claim and permitting insureds to obtain estimates of amounts that their insurers will pay for specific health care procedures and services.
Ins 3.60(2)(a)
(a) “C.D.T." means the American dental association's current dental terminology.
Ins 3.60(2)(b)
(b) “C.P.T." means the American medical association's current procedural terminology.
Ins 3.60(2)(c)
(c) “Provider" means a licensed health care professional.
Ins 3.60(3)(a)(a) This section applies to an individual or group health insurance contract or certificate of individual coverage issued in this state that provides for settlement of claims based on a specific methodology, including but not limited to, usual, customary and reasonable charges or prevailing rate in the community, by which the insurer determines the eligible amount of a provider's charge.
Ins 3.60(3)(b)
(b) This section applies to a health maintenance organization to the extent that it makes claim settlement determinations for out-of-plan services as described in par.
(a).
Ins 3.60(4)
(4)
Data requirements. Any insurer that issues a policy or certificate subject to this section shall base its specific methodology on a data base that meets all of the following conditions:
Ins 3.60(4)(a)
(a) The fees in the data base shall accurately reflect the amounts charged by providers for health care procedures and services rather than amounts paid to or collected by providers, and may not include any medicare charges or discounted charges from preferred provider organization providers.
Ins 3.60(4)(b)
(b) The data base shall be capable of all of the following:
Ins 3.60(4)(b)1.
1. Compiling and sorting information for providers by C.D.T. code, C.P.T. code or other similar coding acceptable to the commissioner of insurance.
Ins 3.60(4)(b)2.
2. Compiling and sorting by zip code or other regional basis, so that charges may be based on the smallest geographic area that will generate a statistically credible claims distribution.
Ins 3.60(4)(c)
(c) The data base shall be updated at least every 6 months.
Ins 3.60(4)(d)
(d) No data in the data base at the time of an update under par.
(c) may be older than 18 months.
Ins 3.60(4)(e)
(e) If the insurer uses an outside vendor's data base the insurer may supplement it with data from the insurer's own claim experience.
Ins 3.60(4)(f)
(f) An insurer may supplement a statistical data base with other information that establishes that providers accept as payment without balance billing amounts less than their initial or represented charge only if:
Ins 3.60(4)(f)2.
2. The information establishes that the provider generally and as a practice accepts the payment without balance billing regardless of which insurer is providing coverage; and
Ins 3.60(4)(f)3.
3. The information is no older than 18 months before the date of an update under par.
(c), clearly establishes the practice, is documented and is maintained in the insurer's records during the period that the information is used and for 2 years after that date.
Ins 3.60(5)
(5)
Disclosure requirements upon issuance of policy. Ins 3.60(5)(a)
(a) Each policy and certificate subject to this section shall include all of the following:
Ins 3.60(5)(a)1.
1. A clear statement, printed prominently on the first page of the policy or in the form of a sticker, letter or other form included with the policy, that the insurer settles claims based on a specific methodology and that the eligible amount of a claim, as determined by the specific methodology, may be less than the provider's billed charge. This subdivision does not apply to a closed panel health maintenance organization that does not provide coverage for nonemergency services by noncontracted providers.
Ins 3.60(5)(a)2.
2. If the policy or certificate includes a provision offering to defend the insured if a provider attempts to collect any amount in excess of that determined by the insurer's specific methodology, less coinsurance and deductibles, a clear statement that such a provision does not apply if the insured signs a separate agreement with the provider to pay any balance due.
Ins 3.60(5)(b)
(b) At the time a policy or certificate is issued, the insurer shall provide the policyholder or certificate holder with the telephone number of a contact person or section of the company that can furnish insureds with the information required to be disclosed under sub.
(6).
Ins 3.60(6)(a)
(a) Each insurer issuing a policy or certificate subject to this section shall, upon request, provide the insured with any of the following:
Ins 3.60(6)(a)1.
1. A description of the insurer's specific methodology including, but not limited to, the following:
Ins 3.60(6)(a)1.a.
a. The source of the data used, such as the insurer's claim experience, trade association's data, an expert panel of providers or other source.
Ins 3.60(6)(a)1.d.
d. If applicable, the percentile used to determine usual, customary and reasonable charges.
Ins 3.60(6)(a)2.
2. The amount allowable under the insurer's guidelines for determination of the eligible amount of a provider's charge for a specific health care procedure or service in a given geographic area. The insurer is required to disclose the specific amount which is an allowable charge under the insurer's guidelines only if the provider's charge exceeds the allowable charge under the guidelines. The estimate may be in the form of a range of payment or maximum payment.
Ins 3.60(6)(b)
(b) Paragraph
(a) does not require an insurer to disclose specifically enumerated proprietary information prohibited from disclosure by a contract between the insurer and the source of the data in the data base.
Ins 3.60(6)(c)
(c) A request under par.
(a) may be oral or written. The insurer may require the insured to provide reasonably specific details, including the provider's estimated charge, and the C.P.T. or C.D.T. code, about the health care procedure or service before responding to the request. The response may be oral or written and the insurer shall respond within 5 working days after the date it receives a sufficient request. As part of the response, the insurer shall inform the requester of all of the following:
Ins 3.60(6)(c)1.
1. That the policy benefits are available only to individuals who are eligible for benefits at the time a health care procedure or service is provided.
Ins 3.60(6)(c)2.
2. That policy provisions including, but not limited to, preexisting condition and contestable clauses and medical necessity requirements, may cause the insurer to deny a claim.
Ins 3.60(6)(c)3.
3. That policy limitations including, but not limited to copayments and deductibles, may reduce the amount the insurer will pay for a health care procedure or service.
Ins 3.60(6)(c)4.
4. That a policy may contain exclusions from coverage for specified health care procedures or services.
Ins 3.60(6)(d)
(d) An insurer that provides a good faith estimate under par.
(a) 2., based on the information provided at the time the estimate is requested, is not bound by the estimate.
Ins 3.60(6)(e)
(e) Upon request, an insurer shall provide the commissioner of insurance with information concerning the insurer's specific methodology.
Ins 3.60(7)
(7)
Disclosure accompanying payment. If an insurer, based on its specific methodology, determines that the eligible amount of a claim is less than the amount billed, the insurer shall disclose with the remittance advice or explanation of benefits form under s.
Ins 3.651, which accompanies payment to the provider or the insured, the telephone number of a contact person or section of the company from whom the provider or the insured may request the information specified under sub.
(6) (a) 1. Ins 3.60 History
History: Cr.
Register, December, 1992, No. 444, eff. 1-1-93; reprinted to correct copy in (4) (d), (6) (a) 2. and (c) (intro.),
Register, February, 1993, No. 446; r. and recr. (7),
Register, August, 1993, No. 452, eff. 9-1-93.
Ins 3.65
Ins 3.65
Standardized claim format. Ins 3.65(1)(1)
Purpose; applicability. This section implements s.
632.725 (2) (a) and
(b), Stats., by designating and establishing requirements for use of the forms that health care providers in this state shall use on and after July 1, 1993, for providing a health insurance claim form directly to a patient or filing a claim with an insurer on behalf of a patient.
Ins 3.65(2)(a)
(a) “ADA dental claim form" means the uniform dental claim form approved by the American dental association for use by dentists.
Ins 3.65(2)(b)
(b) “CDT-1 codes" means the current dental terminology published by the American dental association.
