Wis. Admin. Code Office of the Commissioner of Insurance Ins 19.07 - Eligible claims

For claims to be eligible for reinsurance payment, the eligible health carrier shall comply with s. 601.83, Stats., and submit claims that comply with the following criteria:

(1) The claims that were paid for as covered benefits by the eligible health carrier under the terms and conditions of the carrier's compliant plan for the applicable benefit year including but not limited to medical, surgical, and prescription drug services and treatments.

(2) The claims that were paid by the eligible health carrier after January 1, of the applicable benefit year and before April 30, of the following calendar year, or a date established by the commissioner.

(3) The cumulative amount of the claims paid that exceeds the applicable attachment point. Claims reported shall not include any amount of cost sharing required to be paid by the enrolled individual or the person responsible for the payment of the enrolled individual's cost sharing. Cost sharing may include any of the following; deductibles, co-insurance, co-payment, visit fees, or similar costs.

(4) The cumulative amount of paid claims shall be reduced by any reimbursement received by the eligible health carrier for the enrolled individual through subrogation, recoupment of overpayments from providers, application of negotiated rates reductions with providers, or recoupment of third-party payment including workers compensation or civil litigation.

Notes

Wis. Admin. Code Office of the Commissioner of Insurance Ins 19.07

Adopted by, CR 19-088: cr. Register November 2021 No. 791, eff. 12/1/2021