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WV Code § 33-45-8 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 45. Ethics and Fairness in Insurer Business Practices|§33-45-8. Exemptions

(a) The provisions of this article do not apply to claims that are not covered under the terms of the health plan.(b) Nothing in this article shall preclude the right of a provider or insurer to pursue any other administrative, civil or criminal proceedings or remedies permitted under state or federal law.(c) The provisions of this article do not apply when there is a good faith dispute about the legitimacy of amount of the claim, or when there is a reasonable basis supported by specific information that such claim was submitted fraudulently or with material misrepresentation.(d) An insurer shall not be considered to be in violation of this article if the insurer's failure to comply is caused in material part by the person submitting the claim or the health insurer's compliance is rendered impossible due to matters beyond the insurer's reasonable control.(e) A provider shall not be considered to be in violation of this article if the failure to comply is caused in material part by the insured or the provider's compliance is rendered impossible due to matters beyond the provider's reasonable control.(f) The provisions of this article do not apply to services provided outside the state.
WV Code § 33-46-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-1. Short Title

This article may be cited as the "Third-Party Administrator Act".
WV Code § 33-46-3 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-3. Written Agreement Necessary

(a) No administrator may act as such without a written agreement between the administrator and the insurer and the written agreement shall be retained as part of the official records of both the insurer and the administrator for the duration of the agreement and for ten years thereafter. The agreement shall contain all provisions required by this statute, except insofar as those requirements do not apply to the functions performed by the administrator.(b) The written agreement shall include a statement of duties that the administrator is expected to perform on behalf of the insurer and the lines, classes or types of insurance which the administrator is to be authorized to administer. The agreement shall make provision with respect to underwriting or other standards pertaining to the business underwritten by the insurer.(c) The insurer or administrator may, with written notice, terminate the written agreement for cause as provided in the agreement. The insurer may suspend the underwriting authority of the administrator during the pendency of any dispute regarding the cause for termination of the written agreement. The insurer shall fulfill any lawful obligations with respect to policies affected by the written agreement, regardless of any dispute between the insurer and the administrator.
WV Code § 33-46-4 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-4. Payment to Administrator

If an insurer uses the services of an administrator, the payment to the administrator of any premiums or charges for insurance by or on behalf of the insured party shall be considered to have been received by the insurer and the payment of return premiums or claim payments forwarded by the insurer to the administrator shall not be considered to have been paid to the insured party or claimant until the payments are received by the insured party or claimant. Nothing in this section limits any right of the insurer against the administrator resulting from the failure of the administrator to make payments to the insurer, insured parties or claimants.
WV Code § 33-46-6 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-6. Approval of Advertising

An administrator may use only advertising pertaining to the business underwritten by an insurer that has been approved in writing by the insurer in advance of its use.
WV Code § 33-46-7 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-7. Responsibilities of the Insurer

(a) If an insurer uses the services of an administrator, the insurer is responsible for determining the benefits, premium rates, underwriting criteria and claims payment procedures applicable to the coverage and for securing reinsurance, if any. The rules pertaining to these matters shall be provided, in writing, by the insurer to the administrator. The responsibilities of the administrator as to any of these matters shall be set forth in the written agreement between the administrator and the insurer.(b) It is the sole responsibility of the insurer to provide for competent administration of its programs.(c) In cases where an administrator administers benefits for more than one hundred certificate holders on behalf of an insurer, the insurer shall, at least semiannually, conduct a review of the operations of the administrator. At least one review shall be an on-site audit of the operations of the administrator.(d) For purposes of this section, "insurer" means a licensed insurance company, prepaid hospital or medical care plan, health maintenance organization or a health care corporation.
WV Code § 33-46-8 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-8. Premium Collection and Payment of Claims

(a) All insurance charges or premiums collected by an administrator on behalf of or for an insurer, and the return of premiums received from that insurer, shall be held by the administrator in a fiduciary capacity. The funds shall be immediately remitted to the person entitled to them or shall be deposited promptly in a fiduciary account established and maintained by the administrator in a federally or state-insured financial institution. The written agreement between the administrator and the insurer shall provide for the administrator to periodically render an accounting to the insurer detailing all transactions performed by the administrator pertaining to the business underwritten by the insurer.(b) If charges or premiums deposited in a fiduciary account have been collected on behalf of or for one or more insurers, the administrator shall keep records clearly recording the deposits in and withdrawals from the account on behalf of each insurer. The administrator shall keep copies of all the records and, upon request of an insurer, shall furnish the insurer with copies of the records pertaining to the deposits and withdrawals.(c) The administrator shall not pay any claim by withdrawals from a fiduciary account in which premiums or charges are deposited. Withdrawals from the account shall be made as provided in the written agreement between the administrator and the insurer. The written agreement shall address, but not be limited to, the following:(1) Remittance to an insurer entitled to remittance;(2) Deposit in an account maintained in the name of the insurer;(3) Transfer to and deposit in a claims-paying account, with claims to be paid as provided for in subsection (d) of this section;(4) Payment to a group policyholder for remittance to the insurer entitled to the remittance;(5) Payment to the administrator of its commissions, fees or charges; and(6) Remittance of return premium to the person or persons entitled to the return premium.(d) All claims paid by the administrator from funds collected on behalf of or for an insurer shall be paid only on drafts or checks of and as authorized by the insurer.
WV Code § 33-46-9 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-9. Compensation to the Administrator

(a) An administrator may not enter into an agreement or understanding with an insurer in which the effect is to make the amount of the administrator's commissions, fees or charges contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer's obligations. This provision shall not prohibit an administrator from receiving performance-based compensation for providing hospital or other auditing services.(b) This section shall not prevent the compensation of an administrator from being based on premiums or charges collected or the number of claims paid or processed.
WV Code § 33-46-10 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-10. Notice to Covered Individuals; Disclosure of Charges and Fees

(a) When the services of an administrator are used, the administrator shall provide a written notice approved by the insurer to covered individuals advising them of the identity of, and relationship among, the administrator, the policyholder and the insurer.(b) When an administrator collects funds, the reason for collection of each item shall be identified to the insured party and each item shall be shown separately from any premium. Additional charges may not be made for services to the extent the services have been paid for by the insurer.(c) The administrator shall disclose to the insurer all charges, fees and commissions received from all services in connection with the provision of administrative services for the insurer, including any fees or commissions paid by insurers providing reinsurance.
WV Code § 33-46-11 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-11. Delivery of Materials to Covered Individuals

Any policies, certificates, booklets, termination notices or other written communications delivered by the insurer to the administrator for delivery to insured parties or covered individuals shall be delivered by the administrator promptly after receipt of instructions from the insurer to deliver them.
WV Code § 33-46-13 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-13. Registration Requirement

A person who directly or indirectly underwrites, collects charges or premiums from, or adjusts or settles claims on residents of this state, in connection with life, annuity or accident and sickness coverage provided by a self-funded plan other than a governmental or church plan shall register with the commissioner annually, verifying its status as in this article described.
WV Code § 33-46-15 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-15. Fees and Charges

Except where it is otherwise specially provided, the commissioner shall assess third-party administrators the following fees: For annual fee for each license, $200; for receiving and filing annual reports, $100; for filing a certified copy of articles of incorporation, $50; for filing a copy of its charter, $50; for filing statements preliminary to admission, $100; for filing any additional paper required by law or furnishing copies of the additional paper, $1; and for every copy of a report or certificate of condition of administrator to be filed in any other state, $25. The commissioner may by rule set reasonable charges for printed forms for the annual statements required by law. He or she may sell at cost publications purchased by, or printed on behalf of the commissioner. All fees and moneys collected shall be used for the purposes set forth in section thirteen, article three of this chapter.
WV Code § 33-46-16 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-16. Annual Report and Filing Fee

(a) Each administrator licensed under section twelve of this article shall file an annual report for the preceding calendar year with the commissioner on or before July 1, of each year or within an extension of time granted by the commissioner for good cause. The annual report shall include an audited financial statement performed by an independent certified public accountant. An audited financial/annual report prepared on a consolidated basis shall include a columnar consolidating or combining worksheet that shall be filed with the report and include the following:(1) Amounts shown on the consolidated audited financial report;(2) Amounts for each entity stated separately; and (3) Explanations of consolidating and eliminating entries.The report shall be in the form and contain any matters prescribed by the commissioner and shall be verified by at least two officers of the administrator.(b) The annual report shall include the complete names and addresses of all insurers with which the administrator had agreements during the preceding fiscal year.(c) At the time of filing its annual report, the administrator shall pay the filing fee provided in section fifteen of this article.(d) The commissioner shall review the most recently filed annual report of each administrator on or before September 1, of each year. Upon completion of its review, the commissioner shall either:(1) Issue a certification to the administrator that the annual report shows that the administrator has a positive net worth as evidenced by audited financial statements and is currently licensed and in good standing, or noting any deficiencies found in that annual report and financial statements; or(2) Update any electronic database maintained by the national association of Insurance Commissioners, its affiliates or subsidiaries, indicating the annual report shows that the administrator has a positive net worth as evidenced by audited financial statements and is in compliance with existing law, or noting any deficiencies found in the annual report.
WV Code § 33-46-18 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-18. Exemption for Administrators of Public Health Programs

Programs supervised by the Department of Health and Human Resources, pursuant to chapter nine of this code; the Public Employees Insurance Agency, pursuant to articles sixteen and sixteen-c, chapter five of this code; and the Department of Administration, pursuant to article sixteen-b, chapter five of this code, are exempted from the provisions of this article. Third-party administrators who administer the above-referenced programs are exempt from the provisions of this article with respect to these specific programs only.
WV Code § 33-46-19 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-19. Unauthorized Business

The unauthorized conduct of the business of an administrator shall be treated as unauthorized insurance business and shall be subject to the same criminal and civil penalties as provided in article forty-four for violation of the unauthorized insurers act.
WV Code § 33-46-20 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46. Third-Party Administrator Act|§33-46-20. Commissioner Authorized to Propose Rules

The Insurance Commissioner may propose rules for legislative approval in accordance with the provisions of article three, chapter twenty-nine-a of this code that are necessary to effectuate this article.
WV Code § 33-46A-1 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46A. Professional Employer Organizations|§33-46A-1. Purpose and Intent

The Legislature hereby finds that:(1) Professional Employer Organizations (hereinafter "PEOs") provide a valuable service to commerce and the citizens of this state by increasing the opportunities of employers to develop cost-effective methods of satisfying their personnel requirements and providing employees with access to certain employment benefits which might otherwise not be available to them;(2) PEOs operating in this state should be properly recognized and regulated by the Insurance Commissioner; and(3) Any allocation of employer duties and responsibilities between a PEO and a client-employer pursuant to this article should preserve all rights to which covered employees would be entitled under a traditional employment relationship.
WV Code § 33-46A-2 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46A. Professional Employer Organizations|§33-46A-2. Definitions

(a) "Administrative fee" means the amount charged to a client-employer by a PEO for professional employer services. It does not include amounts paid by a client-employer to the PEO for wages and salaries, benefits, payroll taxes, withholding or assessments paid by the PEO to or on behalf of covered employees under the professional employer agreement.(b) "Client-employer" means an employer who enters into a professional employer agreement with a PEO.(c) "Covered employee" means a person employed by a client-employer for whom certain employer responsibilities are shared or allocated pursuant to a PEO agreement. Persons who are officers, directors, shareholders, partners and managers of the client-employer and who perform day-to-day operational services for the client-employer will be covered employees only to the extent expressly set forth in the professional employer agreement.(d) "PEO group" means two or more PEOs that are majority owned or commonly controlled by the same entity, parent or controlling persons.(e) "Person" means a natural person or a legal entity, including, without limitation, a sole proprietorship, firm, partnership, limited liability company, association, trust or corporation.(f) "Professional employer agreement" means a written contract by and between a client-employer and a PEO under which a PEO contracts to provide professional employer services for an administrative fee.(g) "Professional employer organization" or "PEO" means a person engaged in the business of providing professional employer services, regardless of its use of the term, or conducting business as a "staff leasing company," "registered staff leasing company," "employee leasing company," "administrative employer," or any other name. For purposes of this article, the following is not a PEO: (1) A person who shares employees with a commonly-owned company within the meaning of section 414(b) and (c) of the Internal Revenue Code of 1986, as amended;(2) A person who neither holds itself out as a PEO, nor enters into professional employer agreements as its principal business activity;(3) An independent contractor who assumes responsibility for the product produced or service performed by a person or his or her agents and who retains and exercises primary direction and control over the work performed; or(4) A person who provides temporary help services.(h) "Professional employer services" means functions that are: (1) Allocated to a PEO in a PEO agreement;(2) Customarily exercised by an employer with respect to its employees, including, but not limited to, hiring, firing and disciplining employees, paying wages, withholding and paying payroll taxes, maintaining employee benefit plans, and providing for mandatory workers' compensation coverage;(3) Exercised with respect to a majority of the employees of a client-employer; and(4) Intended to be of a continuing rather than a temporary or seasonal nature.(j) "Worksite employees" means persons employed by a PEO and not by a client-employer.
WV Code § 33-46A-3 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46A. Professional Employer Organizations|§33-46A-3. Rights, Duties and Obligations Unaffected by This Article

(a) Nothing in this article or in any professional employer agreement affects, modifies or amends any collective bargaining agreement, or the rights or obligations of a client-employer, PEO or covered employee under the Federal National Labor Relations Act, the Federal Railway Labor Act or article one-a, chapter twenty-one of this code.(b) Notwithstanding any other provision of this article, nothing in this article or in any professional employer agreement:(1) Diminishes, abolishes or removes rights of covered employees as to a client-employer or obligations of a client-employer to covered employees, including but not limited to rights and obligations arising from civil rights laws guaranteeing nondiscrimination in employment practices;(2) Affects, modifies, or amends any contractual relationship or restrictive covenant between a covered employee and a client-employer in effect at the time a professional employer agreement becomes effective; or(3) Prohibits or amends or any contractual relationship or restrictive covenant that is entered into subsequent to the effective date of a professional employer agreement between a client-employer and a covered employee.
WV Code § 33-46A-4a (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46A. Professional Employer Organizations|§33-46A-4a. Operation of a Peo Without a License; Enforcement; Penalties; Fraud Unit May Investigate

(a) Any person who operates a PEO without a license issued in accordance with this article is subject to the all of the injunctive, criminal, civil and administrative relief and criminal penalties as provided in article forty-four of this chapter for the unauthorized transaction of insurance.(b) In addition to the other investigative authority granted to the commissioner in this chapter, the insurance fraud unit created pursuant to the provisions of section eight, article forty-one of this chapter may investigate suspected violations of this article.
WV Code § 33-46A-5 (2021)
2021 West Virginia Code|Chapter 33. Insurance|Article 46A. Professional Employer Organizations|§33-46A-5. Examinations; Costs; Confidentiality of Information

(a) The commissioner may examine or investigate the business and affairs of any PEO plan he or she considers necessary. The examination or investigation is subject to and shall be performed in accordance with the provisions of section nine, article two of this chapter.(b) The commissioner shall assess the costs of an examination to the PEO.(c) All working papers, recorded information, documents and copies thereof produced by, obtained by or disclosed to the commissioner or any other person in the course of an examination made under this section are subject to the confidentiality provisions of subdivision (4), subsection (l), section nine, article two of this chapter.