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:
Ins 3.651(4)(a)5.d.
d. The amount charged by the health care provider if the insured may be liable for any of the difference between the amount charged and the amount allowed by the insurer.
Ins 3.651(4)(a)5.e.
e. The amount allowed by the insurer. An insurer may modify this requirement if necessary to provide information relating to supplemental insurance.
Ins 3.651(4)(a)5.f.
f. Each claim adjustment reason code, unless the claim is for a dental procedure for which there is no applicable code, in which case the insurer shall provide an appropriate narrative explanation as a replacement for the information required under subd.
7. Ins 3.651(4)(a)6.
6. A general description of each procedure performed or service provided.
Ins 3.651(4)(a)7.
7. A narrative explanation of each claim adjustment reason code. An insurer may provide information in addition to the narrative accompanying the code on form OCI 17-007.
Ins 3.651(4)(b)
(b) Unless requested by the insured, an insurer is not required to provide an explanation of benefits if the insured has no liability for payment for any procedure or service, or is liable only for a fixed dollar copayment which is payable at the time the procedure or service is provided.
Ins 3.651(5)
(5)
Claim adjustment reason codes; use. The office shall prepare updated claim adjustment reason code forms at least semiannually and shall notify insurers of their availability. In preparing remittance advice and explanation of benefits forms, an insurer shall use the claim adjustment reason codes provided by the office of the commissioner of insurance by no later than the first day of the 4th month beginning after being notified that an updated list of codes is available.
Ins 3.651 History
History: Cr.
Register, August, 1993, No. 452, eff. 9-1-93; emer. r. and recr. (3) and (5), renum. (4) (a) 5. b., c. and 8. to 11. to be (4) (a) 5. c., b. and 8. a. to d., am. (4) (a) 6. and 7., cr. (4) (a) 8. (intro.), eff. 10-1-93; r. and recr. (3) and (5), renum. (4) (a) 5. b., c. and 8. to 11. to be (4) (a) 5. c., b. and 8. a. to d., am. (4) (a) 6. and 7., cr. (4) (a) 8. (intro.),
Register, February, 1994, No. 458, eff. 3-1-94.
Ins 3.67
Ins 3.67
Benefit appeals under certain policies. Ins 3.67(1)(am)
(am) “Expedited request" means a request where the standard resolution process may include any of the following:
Ins 3.67(1)(am)1.
1. Serious jeopardy to the life or health of the enrollee or the ability of the enrollee to regain maximum function.
Ins 3.67(1)(am)2.
2. In the opinion of a physician with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.
Ins 3.67(1)(am)3.
3. Is determined to be an expedited request by a physician with knowledge of the enrollee's medical condition.
Ins 3.67(1)(b)
(b) “Grievance" means any dissatisfaction with the provision of services or claims practices of an insurer offering a defined network plan, limited service health organization or preferred provider plan or administration of a defined network plan, limited service health organization or preferred provider plan by the insurer that is expressed in writing to the insurer by, or on behalf of, an enrollee.
Ins 3.67(1)(c)
(c) “Health care plan" has the meaning provided under s.
628.36 (2) (a) 1., Stats., including fixed indemnity and specified disease insurance but does not include coverage ancillary to property and casualty insurance and Medicare + Choice plans.
Ins 3.67(2)
(2)
Drugs and devices. A health care plan or self-insured plan that provides coverage of only certain specified prescription drugs or devices shall develop a process through which an enrollee's physician may present medical evidence to obtain an individual patient exception for coverage of a prescription drug or device.
Ins 3.67(3)(a)
(a) Any coverage limitations for experimental treatment shall be defined and clearly disclosed in every policy issued by a health care plan or self-insured plan in accordance with s.
632.855 (2), Stats.
Ins 3.67(3)(b)
(b) A health care plan or self-insured plan that limits coverage for experimental treatment shall have an internal procedure consistent with s.
632.855 (3), Stats., including issuing a written coverage decision within 5 business days of receipt of the request.
Ins 3.67(4)
(4)
Appeal procedure. The procedure for defined network plan enrollees to appeal a decision under subs.
(2) and
(3) is delineated under s.
Ins 18.03. For other health care plans, the appeal procedure established under this section shall include all of the following:
Ins 3.67(4)(a)
(a) The opportunity for the policyholder or certificate holder, or an authorized representative of the policyholder or certificate holder, to submit a written request, which may be in any form and which may include supporting material, for review by the insurer of the denial of any benefits under the policy.
Ins 3.67(4)(b)
(b) If an insurer denies any benefit under sub.
(2) or
(3), the insurer shall, at the time the insurer gives notice of the denial of benefits, provide the policyholder with a written description of the appeal process.
Ins 3.67(4)(c)
(c) The health care plan or self-insured plan shall acknowledge, in writing, a request for review of coverage under sub.
(2), within 5 business days of receiving it.
Ins 3.67(4)(d)
(d) Within 30 calendar days after receiving the request under sub.
(2) or
(3), the health care plan or self-insured plan shall provide the disposition of the review and notify the person who submitted the request for review of the results of the review.
Ins 3.67(4)(e)
(e) A process to resolve an expedited request for review as expeditiously as the health condition requires but not to exceed 72 hours from the receipt of a substantially completed request under sub.
(2) or
(3).
Ins 3.67(4)(f)
(f) An insurer shall describe the procedure established under this subsection in every policy, group certificate and outline of coverage issued in connection with a health care plan.
Ins 3.67(4)(g)
(g) Each insurer offering a health care plan shall keep together, at its home or principal office, all records of appeals under this subsection. The insurer shall make these records available for review during examinations or at the request of the commissioner.
Ins 3.67 History
History: Cr.
Register, February, 2000, No. 530, eff. 3-1-00; correction in (1) (e) made under s. 13.93 (2m) (b) 7., Stats.,
Register December 2002 No. 564; correction in (4) made under s. 13.93 (2m) (b) 7., Stats.,
Register April 2003 No. 568;
CR 05-059: renum. (1) (a) and (e) to be (1) (am) and (a), am. (1) (a) and (b) and (4) (intro.)
Register February 2006 No. 602, eff. 3-1-06.
Ins 3.75
Ins 3.75
Continuation of discontinued employer provided health group policy coverage for employees and their dependents.
