AB1039: Bill Text

Current law does not regulate the use of current procedural terminology codes (numbers on a health insurance claim form that indicate the services that a health care provider performed). This bill requires an insurer who changes the current procedural terminology code that the health care provider put on the health insurance claim form to include on the explanation of benefits form the reason for the change and to cite the source for the change.

For further information see the state and local fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB1039, s. 1 Section 1. 446.04 (6) of the statutes is created to read:

AB1039,3,4 446.04 (6) Conducting an independent evaluation under s. 632.875 that is not conducted under generally acceptable community standards or guidelines, or standards approved by the chiropractic examining board by rule.

AB1039, s. 2 Section 2. 601.31 (1) (kr) of the statutes is created to read:

AB1039,3,8 601.31 (1) (kr) For maintaining, processing, and providing public access to the written statements under s. 632.875 (4m), an amount set by the commissioner, not to exceed actual costs.

AB1039, s. 3 Section 3. 632.27 of the statutes is created to read:

AB1039,3,13 632.27 Persons to whom settlement checks payable. If an insurer under a liability insurance policy settles a claim made under the policy by an insured or injured 3rd party and pays the settlement amount in a lump sum, the insurer shall pay by a check or other draft that is made payable to all of the following:

AB1039,3,14 (1) The insured or injured 3rd party making the claim.

AB1039,3,16 (2) Any attorney representing the insured or injured 3rd party with respect to the claim.

AB1039,3,17 (3) Any person with respect to whom all of the following apply:

AB1039,3,19 (a) The person provided services to the insured or injured 3rd party on account of the injury to which the claim relates and the services are covered under the policy.

AB1039,4,3 (b) Before payment of the settlement, the person sent to the insurer by certified mail an assignment of benefits form with respect to the services provided and the insurer received the assignment of benefits form.

AB1039,4,5 (c) The assignment of benefits form was completed, signed by the insured or injured 3rd party, and in substantially the following form:

AB1039,4,6 ASSIGNMENT OF BENEFITS OR PAYMENT

AB1039,4,8 I, .... (insured or injured 3rd party), (have insurance with) (have a claim against) the .... insurance company. I have received services from .....

AB1039,4,10 Describe the services provided, including the date(s), and the reason(s) for the services:

AB1039,4,15 I hereby assign to .... (provider of the services) any right that I have to payment, including interest from the above insurance company for the services provided. I understand that I am still ultimately responsible for payment for the services.

AB1039,4,16 Date: ....

AB1039,4,17 Signature of insured or injured 3rd party: ....

AB1039,4,18 I hereby accept the above assignment.

AB1039,4,19 Signature of service provider: ....

AB1039, s. 4 Section 4. 632.726 of the statutes is created to read:

AB1039,4,24 632.726 Current procedural terminology code changes. (1) In this section, "current procedural terminology code" means a number established by the American Medical Association that a health care provider puts on a health insurance claim form to describe the services that he or she performed.

AB1039,5,5 (2) If an insurer changes a current procedural terminology code that was submitted by a health care provider on a health insurance claim form, the insurer shall include on the explanation of benefits form the reason for the change to the current procedural terminology code and shall cite on the explanation of benefits form the source for the change.

AB1039, s. 5 Section 5. 632.87 (3) (b) 1. of the statutes is amended to read:

AB1039,5,11 632.87 (3) (b) 1. Restrict or terminate coverage for the treatment of a condition or a complaint by a licensed chiropractor within the scope of the chiropractor's professional license on the basis of other than an examination or independent evaluation by or a recommendation of a licensed chiropractor or a peer review committee that includes a licensed chiropractor, as defined in s. 632.875 (1) (b).

AB1039, s. 6 Section 6. 632.87 (3) (b) 5. of the statutes is created to read:

AB1039,5,15 632.87 (3) (b) 5. Establish copayment or coinsurance requirements for the services of a chiropractor that are higher than copayment or coinsurance requirements for the services of a licensed physician or osteopath.

AB1039, s. 7 Section 7. 632.874 of the statutes is created to read:

AB1039,5,21 632.874 Payments to chiropractors. An insurer under a health care plan, as defined in s. 628.36, shall pay a chiropractor directly for any covered services the chiropractor provides to an insured under the health care plan who has assigned to the chiropractor his or her claim for payment, reimbursement, or benefits under the health care plan.

AB1039, s. 8 Section 8. 632.875 (1) (am) of the statutes is created to read:

AB1039,5,25 632.875 (1) (am) "Evaluating chiropractor" means a chiropractor who has been in practice at least 10 years and, unless the chiropractor is unable due to disability, is practicing, on an annual basis, an average of 20 hours per week.

AB1039, s. 9 Section 9. 632.875 (1) (b) of the statutes is amended to read:

AB1039,6,5 632.875 (1) (b) "Independent evaluation" means an examination or evaluation by or recommendation of a an evaluating chiropractor or a peer review committee under s. 632.87 (3) (b) 1. whose membership includes at least one evaluating chiropractor.

AB1039, s. 10 Section 10. 632.875 (2) (g) of the statutes is amended to read:

AB1039,6,9 632.875 (2) (g) A reasonable detailed explanation of the factual basis clinical rationale and of the basis in the policy, plan, or contract or in applicable law for the insurer's restriction or termination of coverage.

AB1039, s. 11 Section 11. 632.875 (2) (i) of the statutes is created to read:

AB1039,6,13 632.875 (2) (i) The name of the evaluating chiropractor or, if a peer review committee conducted the independent evaluation, the names of all of the evaluating chiropractors on the peer review committee.

AB1039, s. 12 Section 12. 632.875 (4m) of the statutes is created to read:

AB1039,6,17 632.875 (4m) (a) Following an independent evaluation or any decision made during an appeal, an insurer shall prepare a written statement, containing all of the following:

AB1039,6,19 1. All treatment and costs of the treatment, if any, for which coverage was approved.

AB1039,6,21 2. All treatment and costs of the treatment, if any, for which coverage was restricted.

AB1039,6,23 3. All treatment and costs of the treatment, if any, for which coverage was terminated.

AB1039,6,24 4. The name of the insurer.

AB1039,7,3 5. The name of the evaluating chiropractor or, if a peer review committee conducted the independent evaluation, the names of all of the evaluating chiropractors on the peer review committee.

AB1039,7,7 (b) The insurer shall submit annually a summary, for each evaluating chiropractor or peer review committee that conducted an independent evaluation in the previous year, of all of the written statements required under this subsection to the office on a date that the office determines.

AB1039,7,10 (c) The office shall make the information submitted under par. (b) available to the public on the office's Internet site within a reasonable time period after the insurer submits it.

AB1039,7,12 (d) Every insurer required under this subsection to submit a written statement shall pay the fee required by s. 601.31 (1) (kr).

AB1039, s. 13 Section 13. Initial applicability.

AB1039,7,16 (1) Settlement checks. The treatment of section 632.27 of the statutes first applies to settlements of claims made under liability insurance policies that are issued or renewed on the effective date of this subsection.

AB1039,7,17 (End)