Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.37 - Notice requirements
(1) PROVIDED INFORMATION. Prior to enrolling
members, insurers offering a defined network plan shall provide to prospective
group or individual policyholders information on the plan including all of the
following:
(a) Covered services.
(b) A definition of emergency and out-of-area
coverage.
(c) Cost sharing
requirements.
(d) Enrollment
procedures.
(e) Limitations on
benefits including limitations on choice of providers and the geographical area
serviced by the plan.
(2) PROVIDER DIRECTORIES. Insurers offering a
defined network plan shall make current provider directories available to
enrollees upon enrollment, and no less than annually, following the first year
of enrollment. Preferred provider plans shall also include the language of
Appendix D.
(3) OBSTETRICIANS AND
GYNECOLOGISTS. Insurers offering a defined network plan that permits
obstetricians or gynecologists to serve as primary care providers shall clearly
so state in enrollment materials. Insurers offering a defined network plan that
limits access to obstetricians and gynecologists shall clearly so state in
enrollment materials the process for obtaining referrals.
(4) STANDING REFERRAL CRITERIA. Insurers
offering a defined network plan other than a preferred provider plan shall make
information available to their enrollees describing the criteria for obtaining
a standing referral to a specialist, including under what circumstances and for
what services a standing referral is available, how to request a standing
referral, and how to appeal a standing referral determination. For purposes of
s.
609.22(4),
Stats., and this subsection, referral includes prior authorization for services
if the insurer uses this or similar methods for denying standing referrals to
specialists without just cause and with such frequency to indicate a general
business practice, as determined by the commissioner.
Notes
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