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 HistoryHistory: 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 NoteNote: 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 3.60Ins 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.