Senator Deidre M. Henderson proposes the following substitute bill:





Chief Sponsor: Norman K Thurston

Senate Sponsor: Deidre M. Henderson


9     General Description:
10           This bill addresses payments to health care providers through coordination of benefits.
11     Highlighted Provisions:
12          This bill:
13          ▸     requires a health care provider to return overpayments, with interest, to patients in
14     certain circumstances.
15     Money Appropriated in this Bill:
16          None
17     Other Special Clauses:
18          None
19     Utah Code Sections Affected:
20     AMENDS:
21          31A-26-301.5, as last amended by Laws of Utah 2001, Chapter 240

23     Be it enacted by the Legislature of the state of Utah:
24          Section 1. Section 31A-26-301.5 is amended to read:
25          31A-26-301.5. Health care claims practices.

26          (1) Except as provided in Section 31A-8-407, an insured retains ultimate responsibility
27     for paying for health care services the insured receives. If a service is covered by one or more
28     individual or group health insurance policies, all insurers covering the insured have the
29     responsibility to pay valid health care claims in a timely manner according to the terms and
30     limits specified in the policies.
31          (2) (a) Except as provided in Section 31A-22-610.1, a health care provider may bill and
32     collect for any deductible, copayment, or uncovered service.
33          (b) A health care provider may bill an insured for services covered by health insurance
34     policies or may otherwise notify the insured of the expenses covered by the policies. However,
35     a provider may not make any report to a credit bureau, use the services of a collection agency,
36     or use methods other than routine billing or notification until the later of:
37          (i) the expiration of the time afforded to an insurer under Section 31A-26-301.6 to
38     determine its obligation to pay or deny the claim without penalty; or
39          (ii) in the case of medicare beneficiaries or retirees 65 years of age or older, 60 days
40     from the date medicare determines its liability for the claim.
41          (c) Beginning October 31, 1992, all insurers covering the insured shall notify the
42     insured of payment and the amount of payment made to the provider.
43          (d) A health care provider shall return to an insured any amount the insured overpaid,
44     including interest that begins accruing 45 days after the date of the overpayment, if:
45          (i) the insured has multiple insurers with whom the health care provider has contracts
46     that cover the insured; and
47          (ii) the health care provider becomes aware that the provider has received, for any
48     reason, payment for a claim in an amount greater than the provider's contracted rate allows.
49          (3) The commissioner shall make rules consistent with this chapter governing
50     disclosure to the insured of customary charges by health care providers on the explanation of
51     benefits as part of the claims payment process. These rules shall be limited to the form and
52     content of the disclosures on the explanation of benefits, and shall include:
53          (a) a requirement that the method of determination of any specifically referenced
54     customary charges and the range of the customary charges be disclosed; and
55          (b) a prohibition against an implication that the provider is charging excessively if the
56     provider is:

57          (i) a participating provider; and
58          (ii) prohibited from balance billing.