Wis. Admin. Code Office of the Commissioner of Insurance § Ins 3.60 - Disclosure of information on health care claim settlements

Current through November 29, 2021

(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.
(2)DEFINITIONS. In this section:
(a) "C.D.T." means the American dental association's current dental terminology.
(b) "C.P.T." means the American medical association's current procedural terminology.
(c) "Provider" means a licensed health care professional.
(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.
(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).
(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:
(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.
(b) The data base shall be capable of all of the following:
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.
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.
(c) The data base shall be updated at least every 6 months.
(d) No data in the data base at the time of an update under par. (c) may be older than 18 months.
(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.
(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:
1. The insurer makes the disclosure required under sub. (6) (a) 1. e.;
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
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.
(a) Each policy and certificate subject to this section shall include all of the following:
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.
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.
(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).
(a) Each insurer issuing a policy or certificate subject to this section shall, upon request, provide the insured with any of the following:
1. A description of the insurer's specific methodology including, but not limited to, the following:
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.
b. How frequently the data base is updated.
c. The geographic area used in determining the eligible amount.
d. If applicable, the percentile used to determine usual, customary and reasonable charges.
e. The conditions and procedures under which a statistical data base is supplemented under sub. (4) (f).
2. The amount allowable under the insurer's guidelines for determination of the eligible amount of a provider's charge for a specific health care procedure or service in a given geographic area. The insurer is required to disclose the specific amount which is an allowable charge under the insurer's guidelines only if the provider's charge exceeds the allowable charge under the guidelines. The estimate may be in the form of a range of payment or maximum payment.
(b) Paragraph (a) does not require an insurer to disclose specifically enumerated proprietary information prohibited from disclosure by a contract between the insurer and the source of the data in the data base.
(c) A request under par. (a) may be oral or written. The insurer may require the insured to provide reasonably specific details, including the provider's estimated charge, and the C.P.T. or C.D.T. code, about the health care procedure or service before responding to the request. The response may be oral or written and the insurer shall respond within 5 working days after the date it receives a sufficient request. As part of the response, the insurer shall inform the requester of all of the following:
1. That the policy benefits are available only to individuals who are eligible for benefits at the time a health care procedure or service is provided.
2. That policy provisions including, but not limited to, preexisting condition and contestable clauses and medical necessity requirements, may cause the insurer to deny a claim.
3. That policy limitations including, but not limited to copayments and deductibles, may reduce the amount the insurer will pay for a health care procedure or service.
4. That a policy may contain exclusions from coverage for specified health care procedures or services.
(d) An insurer that provides a good faith estimate under par. (a) 2., based on the information provided at the time the estimate is requested, is not bound by the estimate.
(e) Upon request, an insurer shall provide the commissioner of insurance with information concerning the insurer's specific methodology.
(7)DISCLOSURE ACCOMPANYING PAYMENT. If an insurer, based on its specific methodology, determines that the eligible amount of a claim is less than the amount billed, the insurer shall disclose with the remittance advice or explanation of benefits form under s. Ins 3.651, which accompanies payment to the provider or the insured, the telephone number of a contact person or section of the company from whom the provider or the insured may request the information specified under sub. (6) (a) 1.
(8)VIOLATION. A pattern of providing inaccurate or misleading responses under sub. (6) (c) is a violation of s. 628.34(1) (a), Stats.


Wis. Admin. Code Office of the Commissioner of Insurance § Ins 3.60
Cr. Register, December, 1992, No. 444, eff. 1-1-93; reprinted to correct copy in (4) (d), (6) (a) 2. and (c) (intro.), Register, February, 1993, No. 446; r. and recr. (7), Register, August, 1993, No. 452, eff. 9-1-93.

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