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 HistoryHistory: 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 3.67Ins 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.