Ins 3.60(2)(b)(b) “C.P.T.” means the American medical association’s current procedural terminology.

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)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)(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)1.1. The insurer makes the disclosure required under sub. (6) (a) 1. e.;

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)(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.