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. 4. For each claim, all of the following on a single line:

Ins 3.651(3)(b)4.a. a. The date or dates the service was provided or procedure performed.

Ins 3.651(3)(b)4.b. b. The CPT-4, HCPCS or CDT-1 code.

Ins 3.651(3)(b)4.c. c. The amount charged by the health care provider.

Ins 3.651(3)(b)4.d. d. The amount allowed by the insurer.

Ins 3.651(3)(b)4.e. e. The deductible amount.

Ins 3.651(3)(b)4.f. f. The copayment amount.

Ins 3.651(3)(b)4.g. g. The coinsurance amount.

Ins 3.651(3)(b)4.h. h. The amount of the contractual discount.

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)(b)4.j. j. The amount paid by the insurer toward the charge.

Ins 3.651(3)(c) (c) Grouping of claims required.

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) (d) Format; exceptions. Notwithstanding par. (a) 1. and Appendix A:

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) (4) Explanation of benefits for insureds.

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.