Wisconsin Administrative Code

Ins 14.01 Purpose and scope. (1) PURPOSE. This section interprets ss. 100.203, 600.01 (1) (b) 11., 601.31 (1) (km) and 632.185, Stats. The commissioner finds that a warrantor issuing a vehicle protection product warranty is doing the business of insurance, subject to full applica…

Ins 14.10 Initial registration. A fee of $250 shall be paid to the Office of the Commissioner of Insurance at the time

Ins 14.20 Annual renewal registration. (1) The annual warrantor renewal registration form (OCI 21-051) and an annual fee of $250 shall be filed and paid at the Office of the Commissioner of Insurance on or before April 30 of each year. (2) If the renewal form and fee are not file…

Ins 14.80 Enforcement. This chapter may be enforced under ss. 100.203, 601.41, 601.64, 601.65 or 632.185, Stats. the chapter was last published.

Ins 15.01 Warranty plans. (1) PURPOSE. This section interprets ss. 600.01 (1) (b) 5., 601.04 (2), (3) and (4) and 600.03 (25) (a), Stats., by substituting requirements more specifically appropriate to the characteristics of the business of the issuance of warranties in lieu of th…

Ins 16.01 Annual billings for the examination of domestic insurers. (1) PURPOSE. The purpose of this section is to develop a framework for the regular annual billing of domestic insurers, except for town mutuals and cooperative associations organized under s. 185.981, Stats., to …

Ins 17.001 Definitions. In this chapter: (1) XBoardY means the board of governors established under s. 619.04 (3), Stats. (1m) XCommissionerY means the commissioner of insurance or deputy commissioner acting under s. 601.11 (1) (b), Stats. (2) XFundY means the patients compensati…

Ins 17.005 Purpose. This chapter implements ss. 619.01 and 619.04, Stats., and ch. 655, Stats. History: Cr. Register, June, 1990, No. 414, eff. 7-1-90.

Ins 17.01 Payment of mediation fund fees. (1) PURPOSE. This section implements s. 655.61, Stats., relating to the payment of mediation fund fees. (2) FEE. (a) Each physician subject to ch. 655, Stats., except a resident, and each hospital subject to ch. 655, Stats., shall pay to …

Ins 17.24 Review of classification. (1) Any person insured by the plan or covered by the fund may petition the board for a review of its classification by the plan or fund. The petition shall state the basis for the petitioner[s belief that its classification is incorrect. The bo…

Ins 17.25 Wisconsin health care liability insurance plan. (1) FINDINGS. (a) Legislation has been enacted authorizing the commissioner to promulgate a plan to provide health care liability insurance and liability coverage normally incidental to health care liability insurance for …

Ins 17.26 Payments for future medical expenses. (1) PURPOSE. This section implements s. 655.015, Stats. (3) DEFINITIONS. In this section: the chapter was last published. Ins 17.26 WISCONSIN ADMINISTRATIVE CODE (a) XAccountY means a portion of the fund allocated specifically for t…

Ins 17.27 Filing of financial report. (1) PURPOSE. This section implements s. 655.27 (3) (b), (4) (d) and (5) (e), Stats., for the purpose of setting standards and techniques for accounting, valuing, reserving and reporting of data relating to the financial transactions of the fu…

Ins 17.275 Claims information; confidentiality. (1) PURPOSE. This section interprets ss. 19.35 (1) (a), 19.85 (1) (f), 146.82, 655.26 and 655.27 (4) (b), Stats. (2) OPEN RECORDS; PRIVILEGED OR CONFIDENTIAL FUND RECORDS. Except as provided in s. 601.427 (7), Stats., records of the…

Ins 17.28 Health care provider fees. (1) PURPOSE. This section implements s. 655.27 (3), Stats. (2) SCOPE. This section applies to fees charged to providers for participation in the fund, but does not apply to fees charged for operation of the mediation system under s. 655.61, St…

Ins 17.285 Peer review council. (1) PURPOSE. This section implements ss. 619.04 (5) (b) and (5m) (b), 655.27 (3) (a) 2m. and (bg) 2. and 655.275, Stats. (2) DEFINITIONS. In this section: (a) XAggregate indemnityY means the total amount attributable to an individual provider that …

Ins 17.29 Servicing agent. (1) PURPOSE. This section implements s. 655.27 (2), Stats., relating to contracting for claim services for the fund. (2) CRITERIA. The board shall establish the criteria for the selection of the servicing agent prior to the expiration of each contract t…

Ins 17.30 Peer review council assessments. (1) PURPOSE. This section implements ss. 655.27 (3) (am) and 655.275 (6), Stats., relating to the assessment of fees sufficient to cover the costs, including the costs of administration, of the patients compensation fund peer review coun…

Ins 17.35 Primary coverage; requirements; permissible exclusions; deductibles. (1) PURPOSE. This section implements ss. 631.20 and 655.24, Stats., relating to the approval of policy forms for health care liability insurance subject to s. 655.23, Stats. (2) REQUIRED COVERAGE. To q…

Ins 17.40 Notice to fund of filing of action outside this state. (1) PURPOSE. This section implements s. 655.27 (5) (a) and (b), Stats., relating to the requirement that the fund be notified of an action filed outside this state within 60 days of service of process on the health …

Ins 17.50 Self-insured plans for health care providers. (1) PURPOSE. This section implements s. 655.23 (3) (a), Stats. (2) DEFINITIONS. In this section: (a) XActuarialY means prepared by an actuary meeting the requirements of s. Ins 6.12 who has experience in the field of medical…

Ins 18.01 Definitions. In this chapter: (1) XCommissionerY means the Xcommissioner of insuranceY of this state or the commissioner[s designee. (2) XComplaintY means any expression of dissatisfaction expressed to the insurer by the insured, or an insured[s authorized representativ…

Ins 18.02 Definitions. In addition to the definitions in s. 632.83, Stats., in this subchapter: (1) XHealth benefit planY has the meaning provided in s. 632.83, Stats., and includes Medicare supplement and Medicare replacement plans as defined in s. 600.03 (28p) and (28r), Stats.…

Ins 18.03 Grievances. (1) DEFINITION AND EXPLANATION OF THE GRIEVANCE PROCEDURE. (a) Each insurer offering a health benefit plan shall incorporate within its policies, certificates and outlines of coverage the definition of a grievance as stated in s. Ins 18.01 (4). (b) An insure…

Ins 18.04 Right of the commissioner to request OCI complaints be handled as grievances. The commissioner may require an insurer offering a health benefit plan to treat and process an OCI complaint as a grievance as appropriate, if the commissioner provides a written description o…

Ins 18.05 Expedited grievance procedure. Section Ins 18.03 (2) to (4) and (6) does not apply to expedited grievances. For these situations, an insurer offering a health benefit plan shall develop a separate expedited grievance procedure. An expedited grievance shall be resolved a…

Ins 18.06 Reporting requirements. An insurer offering a health benefit plan shall comply with all of the following requirements: (1) Each record of each complaint and grievance submitted to the insurer shall be kept and retained for a period of at least 3 years. These records sha…

Ins 18.10 Definitions. In addition to the definitions in s. 632.835 (1), Stats., in this subchapter: (1) XAdverse determinationY has the meaning as defined in s. 632.835 (1) (a), Stats. This includes the denial of a request for a referral for out-of-network services when the insu…

Ins 18.105 Annual CPI adjustment for independent review eligibility. (1) PUBLICATION AND EFFECTIVE DATE. The commissioner shall publish to the office of the commissioner of insurance website on or before December 1 of each year the consumer price index for urban consumers as dete…

Ins 18.12 Independent review organization procedures. (1) Independent review organizations shall have, and demonstrate compliance with, written policies and procedures governing all aspects of both the standard review and expedited review processes as described in s. 632.835, Sta…

Ins 18.13 Standards of independent review. (1) For coverage denial determinations other than experimental treatment determinations, independent review organizations shall consider any of the following: (a) Medical or scientific evidence including evidence that is determined to be…

Ins 18.14 Approval of independent review organizations. (1) In addition to meeting the requirements established s. 632.835 (4) (a), Stats., any independent review organization seeking approval to conduct independent reviews shall submit an application for approval on a form presc…

Ins 18.16 Independent review organization reporting requirements. (1) An independent review organization shall maintain records on all independent review activity during each calendar year and submit a report to the commissioner, on a form prescribed by the commissioner, by March…

Ins 18.18 Independent review organization fees. (1) A certified independent review organization shall submit its fee schedule in accordance with s. 632.835 (4) (ap), Stats., to the commissioner for review and approval. (2) Fee schedules shall be based on prevailing rates in the i…

Ins 19.01 Purpose. The commissioner implements 2017 Wis. Act 138 for the purposes of establishing the Wisconsin Healthcare Stability Plan. The commissioner will seek to maximize federal funding for the Wisconsin Healthcare Stability Plan. The commissioner shall design and adjust …

Ins 19.02 Definitions. In addition to definitions contained in s. 601.80, Stats., the following definitions shall apply in this chapter: (1) XAuditY has the meaning provided under s. 601.83 (5) (f), Stats., and includes a verification and compliance audit conducted by OCI. (2) XC…

Ins 19.03 Payment parameters. The commissioner shall annually establish the payment parameters for future benefit years through an established procedure that includes all of the following components: (1) The commissioner shall request, under s. 601.42, Stats., all eligible health…

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 c…

Ins 19.10 Reporting requirements. All eligible health carriers shall provide all requested information as ordered by the commissioner pursuant to s. 601.42, Stats. Information collected under ss. Ins 19.07 and 19.11 may be used on an aggregate basis by the commissioner to satisfy…

Ins 19.11 Quarterly reporting requirements. (1) Eligible health carriers shall provide the information required by this section to the commissioner within 45-days from the end of each financial quarter. The data shall be extracted from the health carrier[s claims systems or simil…

Ins 19.12 Final annual report and affirmations. (1) Eligible health carriers shall provide a final annual report to the commissioner by or before May 15 of each calendar year after the applicable benefit year, or a date established by the commissioner. The final annual report sha…

Ins 19.20 Verification audit. (1) The commissioner shall conduct a verification audit of the data submitted for reinsurance payment. The commissioner shall request eligible health carriers to provide information, pursuant to s. 601.42, Stats., including all of the following: (a) …

Ins 19.21 Reinsurance payment calculation. The commissioner shall calculate the dollar amounts eligible for reinsurance payment under s. 601.83 (4) (a), Stats., utilizing the information provided by the eligible health carriers. The commissioner shall consider all of the followin…

Ins 19.22 WIHSP payment reconciliation. The reconciliation period in this section means the time between June 30, or the date the commissioner notifies eligible health carriers of reinsurance payments, through December 31, of the calendar year following the applicable benefit yea…

Ins 19.24 Compliance audit. (1) The commissioner may, at the commissioner[s sole discretion, conduct an audit in accordance with s. 601.83 (5) (f), Stats., with the reasonable audit costs paid by the audited carrier pursuant to s. 601.45 (1), Stats. The commissioner shall give th…

Ins 2.01 Estoppel by report of medical examiner. No company or fraternal benefit society shall issue in this state a contract, based on a medical examination, providing for disability benefits, the provisions of which are in conflict with ss. 632.50 and 632.71, Stats., or shall i…

Ins 2.03 Policies not dated back to lower insurance age. (1) No company shall issue for delivery in this state any policy or contract of life insurance which purports to be issued or take effect as of a date more than 6 months before the application therefor was made, if thereby …