2019 US Virgin Islands Code
Title 22 - Insurance
Chapter 60 - Third Party Administrators
§ 1526. Responsibilities of the payor and TPA
(a) No TPA may act as a TPA without a written agreement between the TPA and the payor. A copy of the agreement must be retained by the TPA for the duration of the agreement and for five years thereafter. The agreement must contain all provisions required by this section, except insofar as the TPA does not perform all the functions referenced in this section.
(b) A payor who uses the services of a TPA retains responsibility for the benefits, premium rates, collateral and reimbursement procedures, underwriting criteria and claims payment procedures applicable to the coverage and for securing reinsurance or stop-loss insurance. The rules pertaining to these matters, to the extent that they are relevant to the duties of the TPA, must be agreed to in writing by the payor and the TPA.
(c) An insurer using the services of a TPA is responsible for the acts of the TPA and is responsible for providing the TPA’s books and records relevant to the insurer to the Commissioner upon request.
(d) The written agreement between the TPA and the payor must provide that communications between the TPA and claimants must avoid deceptive statements regarding the responsibilities of the TPA, payor and any insurer as to claims or premiums.
(e) The TPA and the payor must adhere to the requirements of chapter 49 of this title regarding the prohibition on engaging in unfair practices and fraud.
(f) If a dispute arises between the payor and the TPA regarding which of them is to fulfil a lawful obligation with respect to a policy, certificate or claim, subject to the written agreement, the payor shall fulfill such obligation.
(g) The payor has the duty to ensure competent administration of its programs administered by a TPA and within the scope of this chapter.
(h) When a TPA administers benefits in connection with life, annuity, health and employee benefit stop-loss coverage for more than 100 certificate holders, subscribers, claimants or policyholders on behalf of an insurer, the insurer shall, at least semi-annually, conduct a review of the operations of the TPA. At least one such review must include an on-site audit of the operations of the TPA. The cost of such reviews or audits must be borne by the insurer and not reimbursed by the TPA. The requirements of this subsection do not apply when the TPA and the insurer are affiliated.
(i) Each TPA shall advise the Commissioner of any ownership interest in or affiliation of any kind with any payor responsible directly or through reinsurance for providing benefits to any plan for which the administrator provides services.
(j) The TPA shall file with the Commissioner the names and addresses of the payors with whom the TPA has service agreements. If a payor does not assume or bear the risk, the TPA shall disclose the name and address of the ultimate risk bearer. This filing requirement applies to the initial application for a TPA’s license and for the renewal of TPA license.
(k) The payor owns the records generated by the TPA pertaining to the payor, except that the TPA retains the right to continuing access to books and records to permit the TPA to fulfill all its contractual obligations to the payor.
