044-4 Wyo. Code R. §§ 4-7 - Responsibilities of the Payor and TPA

(a) No TPA shall act as such without a written agreement between the TPA and the payor. A copy of the agreement shall be retained by the TPA for the duration of the agreement and for five (5) years thereafter. The agreement shall contain all provisions required by this section, except insofar as the TPA does not perform all of the functions referenced in this section.

(b) A payor that utilizes the services of a TPA shall retain responsibility for the benefits, premium rates, plan contribution amounts, collateral and reimbursement procedures, underwriting criteria and claims payment procedures applicable to the coverage and for securing reinsurance or stop-loss insurance, if any. The rules pertaining to these matters, to the extent that they are relevant to the duties of the TPA, shall be agreed to in writing by the payor and the TPA.

(c) A payor utilizing the services of a TPA is responsible for the acts of the TPA and is responsible for providing, upon request of the commissioner, any books and records relevant to its relationship with the TPA.

(d) The written agreement between the TPA and the payor shall provide that communications between the TPA and claimants shall avoid deceptive statements with regard to the responsibilities of the TPA, payor and any entity with regard to claims, premiums, or plan contributions.

(e) In the event of a dispute between the payor and the TPA regarding which of them is to fulfill a lawful obligation with respect to a policy, certificate or claim subject to the written agreement, the payor shall fulfill such obligation.

(f) The payor has the duty to provide for competent administration of its programs administered by a TPA and within the scope of this chapter.

Notes

044-4 Wyo. Code R. §§ 4-7

Amended, Eff. 11/2/2022.