31A-8-407. Written contracts -- Limited liability of enrollee -- Provider claim
disputes -- Leased networks.
(1) (a) Every contract between an organization and a participating provider of health care
services shall be in writing and shall set forth that if the organization:
(i) fails to pay for health care services as set forth in the contract, the enrollee may not be
liable to the provider for any sums owed by the organization; and
(ii) becomes insolvent, the rehabilitator or liquidator may require the participating
provider of health care services to:
(A) continue to provide health care services under the contract between the participating
provider and the organization until the earlier of:
(I) 90 days after the date of the filing of a petition for rehabilitation or the petition for
liquidation; or
(II) the date the term of the contract ends; and
(B) subject to Subsection (1)(c), reduce the fees the participating provider is otherwise
entitled to receive from the organization under the contract between the participating provider
and the organization during the time period described in Subsection (1)(a)(ii)(A).
(b) If the conditions of Subsection (1)(c) are met, the participating provider shall:
(i) accept the reduced payment as payment in full; and
(ii) relinquish the right to collect additional amounts from the insolvent organization's
enrollee.
(c) Notwithstanding Subsection (1)(a)(ii)(B):
(i) the rehabilitator or liquidator may not reduce a fee to less than 75% of the regular fee
set forth in the participating provider contract; and
(ii) the enrollee shall continue to pay the same copayments, deductibles, and other
payments for services received from the participating provider that the enrollee was required to
pay before the filing of:
(A) the petition for rehabilitation; or
(B) the petition for liquidation.
(2) A participating provider may not collect or attempt to collect from the enrollee sums
owed by the organization or the amount of the regular fee reduction authorized under Subsection
(1)(a)(ii) if the participating provider contract:
(a) is not in writing as required in Subsection (1); or
(b) fails to contain the language required by Subsection (1).
(3) (a) A person listed in Subsection (3)(b) may not bill or maintain any action at law
against an enrollee to collect:
(i) sums owed by the organization; or
(ii) the amount of the regular fee reduction authorized under Subsection (1)(a)(ii).
(b) Subsection (3)(a) applies to:
(i) a participating provider;
(ii) an agent;
(iii) a trustee; or
(iv) an assignee of a person described in Subsections (3)(b)(i) through (iii).
(c) In any dispute involving a provider's claim for reimbursement, the same shall be
determined in accordance with applicable law, the provider contract, the subscriber contract, and
the organization's written payment policies in effect at the time services were rendered.
(d) If the parties are unable to resolve their dispute, the matter shall be subject to binding
arbitration by a jointly selected arbitrator. Each party is to bear its own expense except the cost
of the jointly selected arbitrator shall be equally shared. This Subsection (3)(d) does not apply to
the claim of a general acute hospital to the extent it is inconsistent with the hospital's provider
agreement.
(e) An organization may not penalize a provider solely for pursuing a claims dispute or
otherwise demanding payment for a sum believed owing.
(4) If an organization permits another private entity with which it does not share common
ownership or control to use or otherwise lease one or more of the organization's networks that
include participating providers, the organization shall ensure, at a minimum, that the entity pays
participating providers in accordance with the same fee schedule and general payment policies as
the organization would for that network unless payment for services is governed by a public
program's fee schedule.
Amended by Chapter 3, 2005 Special Session 1
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Last revised: Thursday, May 28, 2009