Ins 3.60(6)(d) (d) An insurer that provides a good faith estimate under par. (a) 2., based on the information provided at the time the estimate is requested, is not bound by the estimate.

Ins 3.60(6)(e) (e) Upon request, an insurer shall provide the commissioner of insurance with information concerning the insurer’s specific methodology.

Ins 3.60(7) (7) Disclosure accompanying payment. If an insurer, based on its specific methodology, determines that the eligible amount of a claim is less than the amount billed, the insurer shall disclose with the remittance advice or explanation of benefits form under s. Ins 3.651, which accompanies payment to the provider or the insured, the telephone number of a contact person or section of the company from whom the provider or the insured may request the information specified under sub. (6) (a) 1.

Ins 3.60(8) (8) Violation. A pattern of providing inaccurate or misleading responses under sub. (6) (c) is a violation of s. 628.34 (1) (a), Stats.

Ins 3.60 History History: Cr. Register, December, 1992, No. 444, eff. 1-1-93; reprinted to correct copy in (4) (d), (6) (a) 2. and (c) (intro.), Register, February, 1993, No. 446; r. and recr. (7), Register, August, 1993, No. 452, eff. 9-1-93.

Ins 3.65 Ins 3.65 Standardized claim format.

Ins 3.65(1) (1) Purpose; applicability. This section implements s. 632.725 (2) (a) and (b), Stats., by designating and establishing requirements for use of the forms that health care providers in this state shall use on and after July 1, 1993, for providing a health insurance claim form directly to a patient or filing a claim with an insurer on behalf of a patient.

Ins 3.65(2) (2) Definitions. In this section and in s. Ins 3.651:

Ins 3.65(2)(a) (a) “ADA dental claim form” means the uniform dental claim form approved by the American dental association for use by dentists.

Ins 3.65(2)(b) (b) “CDT-1 codes” means the current dental terminology published by the American dental association.

Ins 3.65(2)(c) (c) “CPT-4 codes” means the current procedural terminology published by the American medical association.

Ins 3.65(2)(d) (d) “DSM-III-R codes” means the American psychiatric association’s codes for mental disorders.

Ins 3.65(2)(e) (e) “HCFA” means the federal health care financing administration of the U.S. department of health and human services.

Ins 3.65(2)(f) (f) “HCFA-1450 form” means the health insurance claim form published by HCFA for use by institutional providers.

Ins 3.65(2)(g) (g) “HCFA-1500 form” means the health insurance claim form published by HCFA for use by health care professionals.

Ins 3.65(2)(h) (h) “HCPCS codes” means HCFA’s common procedure coding system which includes all of the following:

Ins 3.65(2)(h)1. 1. Level 1 codes which are the CPT-4 codes.

Ins 3.65(2)(h)2. 2. Level 2 codes which are codes for procedures for which there are no CPT-4 codes.

Ins 3.65(2)(h)3. 3. Levels 1 and 2 modifiers.

Ins 3.65(2)(i) (i) “Health care provider” has the meaning given in s. 632.725 (1), Stats.

Ins 3.65(2)(j) (j) “ICD-9-CM codes” means the disease codes in the international classification of diseases, 9th revision, clinical modification published by the U.S. department of health and human services.

Ins 3.65(2)(k) (k) “Medicare” means Title XVIII of the federal social security act.

Ins 3.65(2)(L) (L) “Medical assistance” means Title XIX of the federal social security act.

Ins 3.65(2)(m) (m) “Revenue codes” means the codes which are included in the Wisconsin uniform billing manual and which are established for use by institutional health care providers by the national uniform billing committee.

Ins 3.65 Note Note: The publications and forms referred to in subsection (2) may be obtained as follows:HCFA-1500 form and instructions

Ins 3.65 Note From the U.S. Government Printing Office, 710 North Capitol Street NW, Washington, DC 20401, all of the following:

Ins 3.65 Note HCPCS codes

Ins 3.65 Note ICD-9-CM codes

Ins 3.65 Note HCFA-1450 form and instructions