Section Ins 9.42 - Compliance program requirements(1) All insurers offering a defined network plan, preferred provider plan or limited service health organization except to the extent otherwise exempted under this chapter or by statute, are responsible for compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., applicable sections of this subchapter and other applicable sections including but not limited to s. Ins 9.07. Insurers offering a defined network plan, preferred provider plan or limited service health organization, to the extent they are required to comply with those provisions, shall establish a compliance program and procedures to verify compliance. Nothing in this section shall affect the availability of the privilege established under s. 146.38, Stats.(2) The insurers shall establish and operate a compliance program that provides reasonable assurance that: (a) The insurer is in compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, 632.83, and 632.83, Stats., this subchapter and other applicable sections including but not limited to s. Ins 9.07.(b) Any violations of ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter or any applicable sections including but not limited to s. Ins 9.07 a redetected and timely corrections are taken by the insurer.(3) The insurer's compliance program shall include regular internal audits, including regular audits of any contractors or subcontractors who perform functions relating to compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter or any applicable sections including but not limited to s. Ins 9.07.(4) An insurer that materially relies upon another party to carry out functions under ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter or any applicable sections including but not limited to s. Ins 9.07, shall do all of the following: (a) Contractually require the other party to carry out those functions in compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter and other applicable sections including but not limited to s. Ins 9.07.(b) Enforce the contractual provisions required under par. (a). (c) Include in the insurer's compliance program provisions to monitor, supervise and audit the performance of the other party in carrying out the functions.(d) Maintain management reports and records reasonably necessary to monitor, supervise and audit the other party's performance.(e) Include and enforce contractual provisions requiring the other party to give the office access to documentation demonstrating compliance with ss. 609.22, 609.24, 609.30, 609.32, 609.34, 609.36, and 632.83, Stats., this subchapter and other applicable sections including but not limited to s. Ins 9.07 within15 days of receipt of notice.(f) Regularly audit compliance with contract provisions including audits of internal working papers and reports.(5) The insurer shall maintain all of the following items in its records: (a) Any audits, and associated work papers of audits, conducted during the period of review relating to the business and service operation of the insurer offering a defined network plan, preferred provider plan or limited service health organization.(b) All provider directories and provider manuals for the period of review. The directory shall include, as an addendum, a list of all providers that disassociated with the insurer or provider network in the review period.(c) A sample copy of the provider agreement, including those with a provider network, for each provider category including hospital, physician, medical clinic, pharmacy, mental health services and chiropractor.(d) Copies of contracts for management services, data management and processing, marketing, administrative services and case management.(e) A sample copy of each certificate form for the period of review including a copy of sample enrollment forms.(6) Except as permitted under sub. (7), an insurer shall maintain a complete record of the following: (a) An access plan developed in accordance with s. Ins 9.32(1) and s. 609.22, Stats., requirements.(b) A quality assurance plan developed in accordance with s. Ins 9.40 and s. 609.32, Stats., requirements including means of identification, evaluation and correction of quality assurance problems.(c) Credentialing policies and procedures and a credentialing plan.(d) Utilization management procedures and policies.(e) Minutes from any committee, physician association, or board of directors meeting pertaining to quality assurance, utilization management, and credentialing.(7) An insurer that complies with subs. (1) to (5), may permit another party to maintain any record required under sub. (6), but only if both of the following requirements are met: (a) The insurer includes and enforces the contractual provision described in sub. (4) (e).(b) The insurer produces any required record within 15 days after the office requests the record.(8) An insurer shall maintain all of the following documents that relate to a silent provider network and shall make them available at the request of the commissioner: (a) Provider and provider network agreements, including addenda addressing reimbursement and discounts.(b) A listing of providers participating in additional group or individual discount contracts with the insurer.(c) Policy form numbers of those insurance products with silent discounts and associated marketing materials.(d) Claims administration guidelines for processing discounts including silent discounts.(e) Detailed documentation and explanation of claim system data fields and codes that identify silent discounts, other discount calculations, usual and customary calculations, and billed and paid amounts.(9) An insurer offering a preferred provider plan that is not also a defined network plan shall comply with this section to the extent applicable.Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.42
Cr. Register, February, 2000, No. 530, eff. 3-1-00; corrections in (1) to (4) made under s. 13.93(2m) (b) 7, Stats., Register November 2001 No. 551; CR 05-059: am. (1) to (3), (4) (a) and (e), (5) (a), and (6) (a), cr. (9) Register February 2006 No. 602, eff. 3-1-06; CR 06-083: am. (1) and (5) (a) Register December 2006 No. 612, eff. 1-1-07.