Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.01 - Definitions
In this chapter, and for the purposes of applying ch. 609, Stats.:
(1) "Acceptable letter of
credit" means a clean, unconditional, irrevocable letter of credit issued by a
Wisconsin bank or any other financial institution acceptable to the
commissioner which renews on an annual basis for a 3-year term unless written
notice of nonrenewal is given to the commissioner and the limited service
health organization at least 60 days prior to the renewal date.
(2) "Commissioner" means the "commissioner of
insurance" of this state or the commissioner's designee.
(3) "Complaint" means any expression of
dissatisfaction expressed to an insurer by an enrollee, or an enrollee's
authorized representative, about the insurer or its participating
providers.
(3m) "Defined network
plan" has the meaning provided under s.
609.01(1b),
Stats., and includes Medicare select policies and certificates, as defined in
s. Ins 3.39(3) (vm) and (ve), respectively, and health benefit plans that
contract for use of participating providers.
(4) "Expedited grievance" means a grievance
where the standard resolution process may include any of the following:
(a) Serious jeopardy to the life or health of
the enrollee or the ability of the enrollee to regain maximum
function.
(b) 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 grievance.
(c) It is determined to be an expedited
grievance by a physician with knowledge of the enrollee's medical
condition.
(5)
"Grievance" means any dissatisfaction with the provision of services or claims
practices of an insurer offering a defined network plan, preferred provider
plan or limited service health organization, or administration of a defined
network, preferred provider plan or limited service health organization, that
is expressed to the insurer by, or on behalf of, an enrollee.
(6) "Health benefit plan" has the meaning
provided under s.
632.745(11),
Stats.
(7) "HMO" or "health
maintenance organization" means a health care plan as defined in s.
609.01(2),
Stats.
(8) "Health maintenance
organization insurer" has the meaning provided under s.
600.03(23c),
Stats.
(9) "Hospital emergency
facility" means any hospital facility that offers services for emergency
medical conditions as described in s.
632.85(1) (a), Stats., within its capability to do so
and in accordance with s.
DHS 124.24, or
the licensure requirements of the jurisdiction in which the hospital
resides.
(9m) "Intermediate entity"
means a provider network, a provider association, a provider leasing
arrangement or other similar entity that contracts with providers for the
rendering of health care services, items or supplies to enrollees of a defined
network plan, preferred provider plan or limited service health organization
and also contracts with the insurer offering a defined network plan, preferred
provider plan or limited service health organization.
(10) "IPA" or "individual practice
association" has the meaning provided under s.
600.03(23g),
Stats.
(11) "Limited service health
organization" means a health care plan as defined in s.
609.01(3),
Stats.
(13) "OCI complaint" means
any written complaint received by the office of the commissioner of insurance
by, or on behalf of, an enrollee of an insurer offering a defined network plan,
preferred provider plan or limited service health organization.
(14) "Office" means the "office of the
commissioner of insurance."
(14m)
"Participating" has the meaning provided under s.
609.01(3m),
Stats., and includes a provider as being under contract with the insurer when
the provider is under contract with an intermediate entity.
(15) "Preferred provider plan" has the
meaning provided under s.
609.01(4),
Stats.
(16) "Primary provider" has
the meaning provided under s.
609.01(5),
Stats.
(17) "Silent provider
network" means one or more participating providers that provide services
covered under a defined network plan where all of the following apply:
(a) The insurer does not include any
incentives or penalties in the defined network plan related to utilization or
failure to utilize the provider.
(b) The only direct or indirect compensation
arrangement the insurer has with the provider provides for compensation that
is:
1. On a fee for service basis and not on a
risk sharing basis, including, but not limited to, capitation, withholds,
global budgets, or target expected expenses or claims;
2. The compensation arrangement provides for
compensation that is not less than 80% of the provider's usual fee or
charge.
(c) The insurer,
in any arrangement described under par. (b), requires that the reduction in
fees will be applied with respect to cost sharing portions of expenses incurred
under the defined network plan to the extent the provider submits the claim
directly to the insurer.
(d) The
provider is not directly or indirectly managed, owned, or employed by the
insurer.
(e) The insurer does not
disclose, market, advertise, provide a telephone service or number relating to,
or include in policyholder or enrollee material information relating to, the
availability of the compensation arrangement described under par. (b), or the
names or addresses of the provider or an entity that maintains a compensation
arrangement described under par. (b), except to the extent required by law in
processing of explanation of benefits. The insurer may not indirectly cause or
permit a prohibited disclosure and may not make any such disclosure in the
course of utilization review or pre-authorization functions.
Notes
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No prior version found.