49.475 Information about assistance program beneficiaries; electronic submission of claims.

(1) Definitions. In this section:

(ar) “Disability insurance policy" has the meaning given in s. 632.895 (1) (a).

(b) “Insurer" has the meaning given in s. 600.03 (27).

(c) “Pharmacy benefits management" means the administration or management of prescription drug benefits provided by an insurer or other 3rd party, including the performance of any of the following services:

1. Dispensation of prescription drugs by mail.

2. Claims processing, retail network management, or payment of claims to pharmacies for prescription drugs dispensed to individuals.

3. Clinical formulary development and management services.

4. Rebate contracting and administration.

5. Conduct of patient compliance, therapeutic intervention, generic substitution, and disease management programs.

(d) “Pharmacy benefits manager" means an entity that performs pharmacy benefits management.

(e) “Recipient" means an individual or his or her spouse or dependent who has been or is one of the following:

1. A recipient of medical assistance or of a program administered under medical assistance under a waiver of federal Medicaid laws.

2. An enrollee of family care.

3. A recipient of the Badger Care health care program.

4. An individual who receives benefits under s. 49.68, 49.683, or 49.685.

5. A participant in the program of prescription drug assistance for elderly persons under s. 49.688.

6. A woman who receives services that are reimbursed under s. 255.06.

(f) “Third party" means an entity that by statute, rule, contract, or agreement is responsible for payment of a claim for a health care item or service, including any of the following:

1. An insurer.

2. An employee benefit plan, as defined in 29 USC 1002 (3).

3. A service benefit plan, as defined in 5 USC 8903 (1).

4. A pharmacy benefits manager.

5. A group health plan, as defined in 29 USC 1191b (a) (1), including a self-insured plan.

6. The issuer of a disability insurance policy.

7. An entity that administers benefits on behalf of another risk-bearing 3rd party, including a 3rd-party administrator, a fiscal intermediary, or a managed care contractor.

(2) Requirements of 3rd parties.

(ac) As a condition of doing business in this state, a 3rd party shall do all of the following:

1. Upon the department's request and in the manner prescribed by the department, provide information to the department necessary for the department to ascertain all of the following with respect to a recipient:

a. Whether the recipient is being or has been provided coverage or a benefit or service by a 3rd party.

b. If subd. 1. a. applies, the nature and period of time of any coverage, benefit, or service provided, including the name, address, and identifying number of any applicable coverage plan.

2. Accept assignment to the department of a right of a recipient to receive 3rd-party payment for an item or service for which payment under medical assistance has been made and accept the department's right to recover any 3rd-party payment made for which assignment has not been accepted.

3. Respond to an inquiry by the department concerning a claim for payment of a health care item or service if the department submits the inquiry less than 36 months after the date on which the health care item or service was provided.

4. If all of the following apply, agree not to deny a claim submitted by the department under subd. 2. solely because of the claim's submission date, the type or format of the claim form, or failure by a recipient to present proper documentation at the time of delivery of the service, benefit, or item that is the basis of the claim:

a. The department submits the claim less than 36 months after the date on which the health care item or service was provided.

b. Action by the department to enforce the department's rights under this section with respect to the claim is commenced less than 72 months after the department submits the claim.

(bc) A 3rd party shall accept the submission of claims from the department under par. (ac) 2. in electronic form and shall timely pay the claims in the manner provided in s. 628.46 (1) and (2). For purposes of timely payment of claims under this paragraph, “written notice" under s. 628.46 (1) includes receipt of a claim in electronic form.

(2m) Limits on information to be provided.

(a) The information that the department may request under this section is limited to the information specified in sub. (2) (ac) 1. and does not include an employer's name unless that information is necessary for the department or a provider to obtain 3rd-party payment for an item or service.

(b) If information under sub. (2) (ac) 1. may be available from more than one source that includes an employer operating a self-insured plan, the department shall seek the information first from a 3rd-party administrator or other entity identified in sub. (1) (f) 7. or pharmacy benefits manager before seeking the information from the employer.

(c) Information obtained under this section may be used only for the purposes specified in this section and in federal law on 3rd-party liability in Medical Assistance programs.

(3) Written agreement. Upon requesting a 3rd party to provide the information under sub. (2) (ac) 1., the department and the 3rd party shall enter into a written agreement that satisfies all of the following:

(a) Identifies the detailed format of the information to be provided to the department.

(b) Includes provisions that adequately safeguard the confidentiality of the information to be disclosed.

(c) Specifies how the 3rd party's reimbursable costs under sub. (5) will be determined and specifies the manner of payment.

(4) Deadline for response; enforcement.

(a) A 3rd party shall provide the information requested under sub. (2) (ac) 1. within 180 days after receiving the department's request if it is the first time that the department has requested the 3rd party to disclose information under this section.

(b) A 3rd party shall provide the information requested under sub. (2) (ac) 1. within 30 days after receiving the department's request if the department has previously requested the 3rd party to disclose information under this section.

(c) If an insurer fails to comply with par. (a) or (b), the department may notify the commissioner of insurance, and the commissioner of insurance may initiate enforcement proceedings against the insurer under s. 601.41 (4) (a).

(d) If a 3rd party other than an insurer fails to comply with par. (a) or (b), the department may so notify the attorney general.

(5) Reimbursement of costs. From the appropriations under s. 20.435 (4) (bm) and (pa), the department shall reimburse a 3rd party that provides information under sub. (2) (ac) 1. for the 3rd party's reasonable costs incurred in providing the requested information, including its reasonable costs, if any, to develop and operate automated systems specifically for the disclosure of the information.

(6) Sharing information. The department of health services shall provide to the department of children and families, for purposes of the medical support liability program under s. 49.22, any information that the department of health services receives under this section. The department of children and families may allow a county child support agency under s. 59.53 (5) or a tribal child support agency access to the information, subject to the use and disclosure restrictions under s. 49.83, and shall consult with the department of health services regarding procedures and methods to adequately safeguard the confidentiality of the information provided under this subsection.

History: 1991 a. 39; 1999 a. 9; 2007 a. 20 ss. 1610 to 1626, 9121 (6) (a); 2011 a. 189; 2013 a. 20.