Ins 3.65(6)(b)(b) Filing claims. A health care provider may file a claim with an insurer using either a paper form or electronic transmission. If a health care provider does not file a claim on behalf of a patient, the health care provider shall provide the patient with the same form that would have been used if the provider had filed a claim on behalf of the patient. Ins 3.65(6)(c)1.1. If the information conveyed by standard coding is insufficient to enable an insurer to determine eligibility for payment, the insurer may require a health care provider to furnish additional medical records to determine medical necessity or the nature of the procedure or service provided. Ins 3.65(6)(c)2.2. The 30-day period allowed for payment of a claim under s. 628.46 (1), Stats., begins when the insurer has sufficient information to determine eligibility for payment. Ins 3.65(6)(d)(d) Use of current forms and codes. In complying with this section, a health care provider shall do all of the following that are applicable: Ins 3.65(6)(d)1.1. Use the most current version of the HCFA-1500 or HCFA-1450 claim form and accompanying instructions by the mandatory effective date HCFA specifies for use in filing medicare claims. Ins 3.65(6)(d)2.2. Begin using modifications to a required coding system for all billing and claim forms by the mandatory effective date HCFA specifies for use in filing medicare claims. Ins 3.65 HistoryHistory: Cr. Register, August, 1993, No. 452, eff. 9-1-93; am. (6) (b), Register, February, 1994, No. 458, eff. 3-1-94; corrections in (4) (a) 2. and 3. made under s. 13.93 (2m) (b) 7., Stats., Register, July, 1999, No. 523; correction in (4) (a) 1. made under s. 13.92 (4) (b) 7., Stats., Register March 2017 No. 735. Ins 3.651Ins 3.651 Standardized explanation of benefits and remittance advice format. Ins 3.651(1)(1) Purpose. This section implements s. 632.725 (2) (c), Stats., by prescribing the requirements for the following, to be used by insurers providing health care coverage to one or more residents of this state: Ins 3.651(1)(a)(a) Remittance advice forms that insurers furnish to health care providers. Ins 3.651(1)(b)(b) Explanation of benefits forms that insurers furnish to insureds. Ins 3.651(2)(2) Definitions. In addition to the definitions in s. Ins 3.65, in this section, “claim adjustment reason codes” means the claim disposition codes of the American national standards institute accredited standards committee X12 (ASC X12). Ins 3.651 NoteNote: The claim adjustment reason codes referenced in subsections (2), (3) (b) 4. i., (4) (a) 5. f. and (5), form OCI 17-007, may be obtained from the Office of the Commissioner of Insurance, P. O. Box 7873, Madison, Wisconsin 53707-7873 or on the Office of the Commissioner of Insurance website at http://oci.wi.gov/. Ins 3.651(3)(a)1.1. With each payment to a health care provider, an insurer shall provide a remittance advice form conforming to the format specified in Appendix A, except as provided in subd. 2. and par. (d). Ins 3.651(3)(a)2.2. The remittance advice form of an insurer with less than $50,000 in annual premiums for health insurance sold in this state, as reported in its most recent annual statement, is not required to conform to the format specified in Appendix A but, with each payment to a health care provider, the insurer shall provide a remittance advice form which includes all of the applicable information specified in par. (b). Ins 3.651(3)(b)(b) Information required. The remittance advice form shall include, at a minimum, all of the following information: Ins 3.651(3)(b)1.1. The insurer’s name and address and the telephone number of a section of the insurer designated to handle questions and appeals from health care providers. Ins 3.651(3)(b)2.2. The insured’s name and policy number, certificate number or both. Ins 3.651(3)(b)3.3. The last name followed by the first name and middle initial of each patient for whom the claim is being paid, the patient identification number and the patient account number, if it has been supplied by the health care provider.