Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.42 - Compliance program requirements
(1) All insurers
offering a defined network plan, preferred provider plan or limited service
health organization except to the extent otherwise exempted under this chapter
or by statute, are responsible for compliance with ss.
609.22,
609.24,
609.30,
609.32,
609.34,
609.36,
and
632.83,
Stats., applicable sections of this subchapter and other applicable sections
including but not limited to s.
Ins 9.07. Insurers offering a defined network plan,
preferred provider plan or limited service health organization, to the extent
they are required to comply with those provisions, shall establish a compliance
program and procedures to verify compliance. Nothing in this section shall
affect the availability of the privilege established under s.
146.38,
Stats.
(2) The insurers shall
establish and operate a compliance program that provides reasonable assurance
that:
(a) The insurer is in compliance with
ss.
609.22,
609.24,
609.30,
609.32,
609.34,
609.36,
632.83,
and
632.83,
Stats., this subchapter and other applicable sections including but not limited
to s.
Ins 9.07.
(b)
Any violations of ss.
609.22,
609.24,
609.30,
609.32,
609.34,
609.36,
and
632.83,
Stats., this subchapter or any applicable sections including but not limited to
s.
Ins 9.07 a redetected and timely corrections are taken by
the insurer.
(3) The
insurer's compliance program shall include regular internal audits, including
regular audits of any contractors or subcontractors who perform functions
relating to compliance with ss.
609.22,
609.24,
609.30,
609.32,
609.34,
609.36,
and
632.83,
Stats., this subchapter or any applicable sections including but not limited to
s.
Ins 9.07.
(4)
An insurer that materially relies upon another party to carry out functions
under ss.
609.22,
609.24,
609.30,
609.32,
609.34,
609.36,
and
632.83,
Stats., this subchapter or any applicable sections including but not limited to
s.
Ins 9.07, shall do all of the following:
(a) Contractually require the other party to
carry out those functions in compliance with ss.
609.22,
609.24,
609.30,
609.32,
609.34,
609.36,
and
632.83,
Stats., this subchapter and other applicable sections including but not limited
to s.
Ins 9.07.
(b)
Enforce the contractual provisions required under par. (a).
(c) Include in the insurer's compliance
program provisions to monitor, supervise and audit the performance of the other
party in carrying out the functions.
(d) Maintain management reports and records
reasonably necessary to monitor, supervise and audit the other party's
performance.
(e) Include and
enforce contractual provisions requiring the other party to give the office
access to documentation demonstrating compliance with ss.
609.22,
609.24,
609.30,
609.32,
609.34,
609.36,
and
632.83,
Stats., this subchapter and other applicable sections including but not limited
to s.
Ins 9.07 within15 days of receipt of notice.
(f) Regularly audit compliance with contract
provisions including audits of internal working papers and
reports.
(5) The insurer
shall maintain all of the following items in its records:
(a) Any audits, and associated work papers of
audits, conducted during the period of review relating to the business and
service operation of the insurer offering a defined network plan, preferred
provider plan or limited service health organization.
(b) All provider directories and provider
manuals for the period of review. The directory shall include, as an addendum,
a list of all providers that disassociated with the insurer or provider network
in the review period.
(c) A sample
copy of the provider agreement, including those with a provider network, for
each provider category including hospital, physician, medical clinic, pharmacy,
mental health services and chiropractor.
(d) Copies of contracts for management
services, data management and processing, marketing, administrative services
and case management.
(e) A sample
copy of each certificate form for the period of review including a copy of
sample enrollment forms.
(6) Except as permitted under sub. (7), an
insurer shall maintain a complete record of the following:
(b) A quality
assurance plan developed in accordance with s.
Ins 9.40 and s.
609.32, Stats.,
requirements including means of identification, evaluation and correction of
quality assurance problems.
(c)
Credentialing policies and procedures and a credentialing plan.
(d) Utilization management procedures and
policies.
(e) Minutes from any
committee, physician association, or board of directors meeting pertaining to
quality assurance, utilization management, and credentialing.
(7) An insurer that complies with
subs. (1) to (5), may permit another party to maintain any record required
under sub. (6), but only if both of the following requirements are met:
(a) The insurer includes and enforces the
contractual provision described in sub. (4) (e).
(b) The insurer produces any required record
within 15 days after the office requests the record.
(8) An insurer shall maintain all of the
following documents that relate to a silent provider network and shall make
them available at the request of the commissioner:
(a) Provider and provider network agreements,
including addenda addressing reimbursement and discounts.
(b) A listing of providers participating in
additional group or individual discount contracts with the insurer.
(c) Policy form numbers of those insurance
products with silent discounts and associated marketing materials.
(d) Claims administration guidelines for
processing discounts including silent discounts.
(e) Detailed documentation and explanation of
claim system data fields and codes that identify silent discounts, other
discount calculations, usual and customary calculations, and billed and paid
amounts.
(9) An insurer
offering a preferred provider plan that is not also a defined network plan
shall comply with this section to the extent applicable.
Notes
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