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8 LONG TITLE
9 General Description:
10 This bill addresses payments to health care providers through coordination of benefits.
11 Highlighted Provisions:
12 This bill:
13 ▸ prevents a health care provider from collecting a payment in an amount greater than
14 the patient's lowest contracted rate; and
15 ▸ requires a health care provider to return overpayments to patients and insurers.
16 Money Appropriated in this Bill:
17 None
18 Other Special Clauses:
19 None
20 Utah Code Sections Affected:
21 AMENDS:
22 31A-26-301.5, as last amended by Laws of Utah 2001, Chapter 240
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24 Be it enacted by the Legislature of the state of Utah:
25 Section 1. Section 31A-26-301.5 is amended to read:
26 31A-26-301.5. Health care claims practices.
27 (1) Except as provided in Section 31A-8-407, an insured retains ultimate responsibility
28 for paying for health care services the insured receives. If a service is covered by one or more
29 individual or group health insurance policies, all insurers covering the insured have the
30 responsibility to pay valid health care claims in a timely manner according to the terms and
31 limits specified in the policies.
32 (2) (a) Except as provided in Section 31A-22-610.1, a health care provider may bill and
33 collect for any deductible, copayment, or uncovered service.
34 (b) A health care provider may bill an insured for services covered by health insurance
35 policies or may otherwise notify the insured of the expenses covered by the policies. However,
36 a provider may not make any report to a credit bureau, use the services of a collection agency,
37 or use methods other than routine billing or notification until the later of:
38 (i) the expiration of the time afforded to an insurer under Section 31A-26-301.6 to
39 determine its obligation to pay or deny the claim without penalty; or
40 (ii) in the case of medicare beneficiaries or retirees 65 years of age or older, 60 days
41 from the date medicare determines its liability for the claim.
42 (c) Beginning October 31, 1992, all insurers covering the insured shall notify the
43 insured of payment and the amount of payment made to the provider.
44 (d) If an insured has multiple insurers:
45 (i) a health care provider may not collect payment for a claim in an amount greater than
46 the lowest contracted rate between the insured and one of the insured's insurers; and
47 (ii) if a health care provider becomes aware, including when an insured presents the
48 provider with an explanation of benefits from an insurer, that the provider has received, for any
49 reason, payment for a claim in an amount greater than the provider's contracted rate allows, the
50 provider shall return, including interest accruing from the date of the overpayment:
51 (A) to the insured, the amount the insured overpaid; and
52 (B) to each insurer, the amount each insurer overpaid.
53 (3) The commissioner shall make rules consistent with this chapter governing
54 disclosure to the insured of customary charges by health care providers on the explanation of
55 benefits as part of the claims payment process. These rules shall be limited to the form and
56 content of the disclosures on the explanation of benefits, and shall include:
57 (a) a requirement that the method of determination of any specifically referenced
58 customary charges and the range of the customary charges be disclosed; and
59 (b) a prohibition against an implication that the provider is charging excessively if the
60 provider is:
61 (i) a participating provider; and
62 (ii) prohibited from balance billing.
Legislative Review Note
Office of Legislative Research and General Counsel