First Substitute H.B. 140

Representative Chad E. Bennion proposes to substitute the following bill:

1 HEALTH CLAIMS PROCESSING AND HEALTH
2 CLAIMS AUDITING ACT
3 2001 GENERAL SESSION
4 STATE OF UTAH
5 Sponsor: Chad E. Bennion
6 This act modifies the Insurance Code. This act amends health care claims practices by
7 adding a limitation to the circumstances in which a health care provider may initiate
8 collection efforts against an insured individual. This act provides an effective date.
9 This act affects sections of Utah Code Annotated 1953 as follows:
10 AMENDS:
11 31A-26-301.5, as last amended by Chapter 198, Laws of Utah 2000
12 Be it enacted by the Legislature of the state of Utah:
13 Section 1. Section 31A-26-301.5 is amended to read:
14 31A-26-301.5. Health care claims practices.
15 (1) Except as provided in Section 31A-8-407 , an insured retains ultimate responsibility for
16 paying for health care services the insured receives. If a service is covered by one or more
17 individual or group health insurance policies, all insurers covering the insured have the
18 responsibility to pay valid health care claims in a timely manner according to the terms and limits
19 specified in the policies.
20 (2) (a) Except as provided in Section 31A-22-610.1 , a health care provider may bill and
21 collect for any deductible, copayment, or uncovered service.
22 (b) A health care provider may bill an insured for services covered by health insurance
23 policies or may otherwise notify the insured of the expenses covered by the policies. However,
24 a provider may not make any report to a credit bureau, use the services of a collection agency, or
25 use methods other than routine billing or notification until the later of:

26 (i) 15 days after the date all insurance companies covering the insured have paid their
27 portion of the claim covered by the policies;
28 (ii) 60 days from the date all insurers covering the insured are billed for the covered
29 service; [or]
30 (iii) 20 days after the provider has submitted to an insurer notice that the provider has
31 submitted all information requested by the insurer that is in the provider's possession related to the
32 claim; or
33 [(iii)] (iv) in the case of medicare beneficiaries or retirees 65 years of age or older, 60 days
34 from the date medicare determines its liability for the claim.
35 (c) [Beginning October 31, 1992, all] All insurers covering the insured shall notify the
36 insured of payment and the amount of payment made to the provider.
37 (3) The commissioner shall make rules consistent with this chapter governing disclosure
38 to the insured of customary charges by health care providers on the explanation of benefits as part
39 of the claims payment process. These rules shall be limited to the form and content of the
40 disclosures on the explanation of benefits, and shall include:
41 (a) a requirement that the method of determination of any specifically referenced
42 customary charges and the range of the customary charges be disclosed; and
43 (b) a prohibition against an implication that the provider is charging excessively if the
44 provider is:
45 (i) a participating provider; and
46 (ii) prohibited from balance billing.
47 Section 2. Effective date.
48 This act takes effect on July 1, 2001.