Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.37

Current through October 28, 2024

Section 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.

Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.37

Cr. Register, February, 2000, No. 530, eff. 3-1-00; CR 05-059: am. (1) to (4) Register February 2006 No. 602, eff. 3-1-06.