1     
WORKERS' COMPENSATION RELATED AMENDMENTS

2     
2016 GENERAL SESSION

3     
STATE OF UTAH

4     
Chief Sponsor: Karen Mayne

5     
House Sponsor: Mike Schultz

6     

7     LONG TITLE
8     General Description:
9           This bill modifies provisions related to reimbursement of hospitals for certain services.
10     Highlighted Provisions:
11          This bill:
12          ▸     requires a study regarding hospital costs;
13          ▸     addresses reasonable standards for hospital costs;
14          ▸      defines terms;
15          ▸     addresses contracting with hospitals;
16          ▸     provides for the reimbursement amount in the absence of a contract;
17          ▸     prohibits balance billing by hospitals;
18          ▸     addresses coordination of benefits; and
19          ▸     makes technical and conforming changes.
20     Money Appropriated in this Bill:
21          None
22     Other Special Clauses:
23          None
24     Utah Code Sections Affected:
25     AMENDS:
26          34A-2-107, as last amended by Laws of Utah 2013, Chapter 43
27          34A-2-407, as last amended by Laws of Utah 2013, Chapter 72

28          34A-2-418, as renumbered and amended by Laws of Utah 1997, Chapter 375
29          34A-2-801, as last amended by Laws of Utah 2014, Chapter 192
30          34A-3-108, as last amended by Laws of Utah 2013, Chapter 72
31     

32     Be it enacted by the Legislature of the state of Utah:
33          Section 1. Section 34A-2-107 is amended to read:
34          34A-2-107. Appointment of workers' compensation advisory council --
35     Composition -- Terms of members -- Duties -- Compensation.
36          (1) The commissioner shall appoint a workers' compensation advisory council
37     composed of:
38          (a) the following voting members:
39          (i) five employer representatives; and
40          (ii) five employee representatives; and
41          (b) the following nonvoting members:
42          (i) a representative of the Workers' Compensation Fund;
43          (ii) a representative of a private insurance carrier;
44          (iii) a representative of health care providers;
45          (iv) the Utah insurance commissioner or the insurance commissioner's designee; and
46          (v) the commissioner or the commissioner's designee.
47          (2) Employers and employees shall consider nominating members of groups who
48     historically may have been excluded from the council, such as women, minorities, and
49     individuals with disabilities.
50          (3) (a) Except as required by Subsection (3)(b), as terms of current council members
51     expire, the commissioner shall appoint each new member or reappointed member to a two-year
52     term beginning July 1 and ending June 30.
53          (b) Notwithstanding the requirements of Subsection (3)(a), the commissioner shall, at
54     the time of appointment or reappointment, adjust the length of terms to ensure that the terms of
55     council members are staggered so that approximately half of the council is appointed every two
56     years.
57          (4) (a) When a vacancy occurs in the membership for any reason, the replacement shall
58     be appointed for the unexpired term.

59          (b) The commissioner shall terminate the term of a council member who ceases to be
60     representative as designated by the member's original appointment.
61          (5) The council shall confer at least quarterly for the purpose of advising the
62     commission, the division, and the Legislature on:
63          (a) the Utah workers' compensation and occupational disease laws;
64          (b) the administration of the laws described in Subsection (5)(a); and
65          (c) rules related to the laws described in Subsection (5)(a).
66          (6) Regarding workers' compensation, rehabilitation, and reemployment of employees
67     who acquire a disability because of an industrial injury or occupational disease the council
68     shall:
69          (a) offer advice on issues requested by:
70          (i) the commission;
71          (ii) the division; and
72          (iii) the Legislature; and
73          (b) make recommendations to:
74          (i) the commission; and
75          (ii) the division.
76          (7) The council shall study how hospital costs may be reduced for purposes of medical
77     benefits for workers' compensation. The council shall report to the Business and Labor Interim
78     Committee the council's recommendations by no later than November 30, 2017.
79          [(7)] (8) The commissioner or the commissioner's designee shall serve as the chair of
80     the council and call the necessary meetings.
81          [(8)] (9) The commission shall provide staff support to the council.
82          [(9)] (10) A member may not receive compensation or benefits for the member's
83     service, but may receive per diem and travel expenses in accordance with:
84          (a) Section 63A-3-106;
85          (b) Section 63A-3-107; and
86          (c) rules made by the Division of Finance pursuant to Sections 63A-3-106 and
87     63A-3-107.
88          Section 2. Section 34A-2-407 is amended to read:
89          34A-2-407. Reporting of industrial injuries -- Regulation of health care

90     providers.
91          (1) As used in this section, "physician" is as defined in Section 34A-2-111.
92          (2) (a) An employee sustaining an injury arising out of and in the course of
93     employment shall provide notification to the employee's employer promptly of the injury.
94          (b) If the employee is unable to provide the notification required by Subsection (2)(a),
95     the following may provide notification of the injury to the employee's employer:
96          (i) the employee's next of kin; or
97          (ii) the employee's attorney.
98          (c) An employee claiming benefits under this chapter or Chapter 3, Utah Occupational
99     Disease Act, shall comply with rules adopted by the commission regarding disclosure of
100     medical records of the employee medically relevant to the industrial accident or occupational
101     disease claim.
102          (3) (a) An employee is barred for any claim of benefits arising from an injury if the
103     employee fails to notify within the time period described in Subsection (3)(b):
104          (i) the employee's employer in accordance with Subsection (2); or
105          (ii) the division.
106          (b) The notice required by Subsection (3)(a) shall be made within:
107          (i) 180 days of the day on which the injury occurs; or
108          (ii) in the case of an occupational hearing loss, the time period specified in Section
109     34A-2-506.
110          (4) The following constitute notification of injury required by Subsection (2):
111          (a) an employer's report filed with:
112          (i) the division; or
113          (ii) the employer's workers' compensation insurance carrier;
114          (b) a physician's injury report filed with:
115          (i) the division;
116          (ii) the employer; or
117          (iii) the employer's workers' compensation insurance carrier;
118          (c) a workers' compensation insurance carrier's report filed with the division; or
119          (d) the payment of any medical or disability benefits by:
120          (i) the employer; or

121          (ii) the employer's workers' compensation insurance carrier.
122          (5) (a) An employer and the employer's workers' compensation insurance carrier, if
123     any, shall file a report in accordance with the rules made under Subsection (5)(b) of a:
124          (i) work-related fatality; or
125          (ii) work-related injury resulting in:
126          (A) medical treatment;
127          (B) loss of consciousness;
128          (C) loss of work;
129          (D) restriction of work; or
130          (E) transfer to another job.
131          (b) An employer or the employer's workers' compensation insurance carrier, if any,
132     shall file a report required by Subsection (5)(a), and any subsequent reports of a previously
133     reported injury as may be required by the commission, within the time limits and in the manner
134     established by rule by the commission made after consultation with the workers' compensation
135     advisory council and in accordance with Title 63G, Chapter 3, Utah Administrative
136     Rulemaking Act. A rule made under this Subsection (5)(b) shall:
137          (i) be reasonable; and
138          (ii) take into consideration the practicality and cost of complying with the rule.
139          (c) A report is not required to be filed under this Subsection (5) for a minor injury, such
140     as a cut or scratch that requires first aid treatment only, unless:
141          (i) a treating physician files a report with the division in accordance with Subsection
142     (9); or
143          (ii) a treating physician is required to file a report with the division in accordance with
144     Subsection (9).
145          (6) An employer and its workers' compensation insurance carrier, if any, required to
146     file a report under Subsection (5) shall provide the employee with:
147          (a) a copy of the report submitted to the division; and
148          (b) a statement, as prepared by the division, of the employee's rights and
149     responsibilities related to the industrial injury.
150          (7) An employer shall maintain a record in a manner prescribed by the commission by
151     rule of all:

152          (a) work-related fatalities; or
153          (b) work-related injuries resulting in:
154          (i) medical treatment;
155          (ii) loss of consciousness;
156          (iii) loss of work;
157          (iv) restriction of work; or
158          (v) transfer to another job.
159          (8) (a) Except as provided in Subsection (8)(b), an employer or a workers'
160     compensation insurance carrier who refuses or neglects to make a report, maintain a record, or
161     file a report as required by this section is subject to a civil assessment:
162          (i) imposed by the division, subject to the requirements of Title 63G, Chapter 4,
163     Administrative Procedures Act; and
164          (ii) that may not exceed $500.
165          (b) An employer or workers' compensation insurance carrier is not subject to the civil
166     assessment under this Subsection (8) if:
167          (i) the employer or workers' compensation insurance carrier submits a report later than
168     required by this section; and
169          (ii) the division finds that the employer or workers' compensation insurance carrier has
170     shown good cause for submitting a report later than required by this section.
171          (c) (i) A civil assessment collected under this Subsection (8) shall be deposited into the
172     Uninsured Employers' Fund created in Section 34A-2-704 to be used for a purpose specified in
173     Section 34A-2-704.
174          (ii) The administrator of the Uninsured Employers' Fund shall collect money required
175     to be deposited into the Uninsured Employers' Fund under this Subsection (8)(c) in accordance
176     with Section 34A-2-704.
177          (9) (a) A physician attending an injured employee shall comply with rules established
178     by the commission regarding:
179          (i) fees for physician's services;
180          (ii) disclosure of medical records of the employee medically relevant to the employee's
181     industrial accident or occupational disease claim;
182          (iii) reports to the division regarding:

183          (A) the condition and treatment of an injured employee; or
184          (B) any other matter concerning industrial cases that the physician is treating; and
185          (iv) rules made under Section 34A-2-407.5.
186          (b) A physician who is associated with, employed by, or bills through a hospital is
187     subject to Subsection (9)(a).
188          (c) A hospital providing services for an injured employee is not subject to the
189     requirements of Subsection (9)(a) except for rules made by the commission that are described
190     in Subsection (9)(a)(ii) or (iii) or Section 34A-2-407.5.
191          (d) The commission's schedule of fees may reasonably differentiate remuneration to be
192     paid to providers of health services based on:
193          (i) the severity of the employee's condition;
194          (ii) the nature of the treatment necessary; and
195          (iii) the facilities or equipment specially required to deliver that treatment.
196          (e) This Subsection (9) does not prohibit a contract with a provider of health services
197     relating to the pricing of goods and services.
198          (10) A copy of the initial report filed under Subsection (9)(a)(iii) shall be furnished to:
199          (a) the division;
200          (b) the employee; and
201          (c) (i) the employer; or
202          (ii) the employer's workers' compensation insurance carrier.
203          (11) (a) As used in this Subsection (11):
204          (i) "Balance billing" means charging a person, on whose behalf a workers'
205     compensation insurance carrier or self-insured employer is obligated to pay medical benefits
206     under this chapter or Chapter 3, Utah Occupational Disease Act, for the difference between
207     what the workers' compensation insurance carrier or self-insured employer reimburses the
208     hospital for covered medical services and what the hospital charges for those covered medical
209     services.
210          (ii) "Covered medical services" means medical services provided by a hospital that are
211     covered by workers' compensation medical benefits under this chapter or Chapter 3, Utah
212     Occupational Disease Act.
213          (iii) "Health benefit plan" means the same as that term is defined in Section

214     31A-22-619.6.
215          (iv) "Self-insured employer" means the same as that term is defined in Section
216     34A-2-201.5.
217          (b) Subject to Subsection (11)(d), a workers' compensation insurance carrier or
218     self-insured employer may contract with a hospital to establish reimbursement rates.
219          (c) Subject to Subsection (11)(d), a workers' compensation insurance carrier or
220     self-insured employer that is reimbursing a hospital that has not entered into a contract
221     described in Subsection (11)(b) shall reimburse the hospital for covered medical services at
222     85% of the billed hospital fees for the covered medical services.
223          (d) A hospital may not engage in balance billing.
224          (e) Covered services paid under a health benefit plan are subject to coordination of
225     benefits in accordance with Sections 31A-22-619.6 and 34A-2-213.
226          [(11)] (12) (a) Subject to appellate review under Section 34A-1-303, the commission
227     has exclusive jurisdiction to hear and determine:
228          (i) whether goods provided to or services rendered to an employee are compensable
229     pursuant to this chapter or Chapter 3, Utah Occupational Disease Act, including:
230          (A) medical, nurse, or hospital services;
231          (B) medicines; and
232          (C) artificial means, appliances, or prosthesis;
233          (ii) except for amounts charged or paid under Subsection (11), the reasonableness of
234     the amounts charged or paid for a good or service described in Subsection [(11)] (12)(a)(i); and
235          (iii) collection issues related to a good or service described in Subsection [(11)]
236     (12)(a)(i).
237          (b) Except as provided in Subsection [(11)] (12)(a), Subsection 34A-2-211(6), or
238     Section 34A-2-212, a person may not maintain a cause of action in any forum within this state
239     other than the commission for collection or payment for goods or services described in
240     Subsection [(11)] (12)(a) that are compensable under this chapter or Chapter 3, Utah
241     Occupational Disease Act.
242          Section 3. Section 34A-2-418 is amended to read:
243          34A-2-418. Awards -- Medical, nursing, hospital, and burial expenses -- Artificial
244     means and appliances.

245          (1) In addition to the compensation provided in this chapter or Chapter 3, Utah
246     Occupational Disease Act, and subject to Subsection 34A-2-407(11), the employer or the
247     insurance carrier shall pay reasonable sums for medical, nurse, and hospital services, for
248     medicines, and for artificial means, appliances, and prostheses necessary to treat the injured
249     employee.
250          (2) If death results from the injury, the employer or the insurance carrier shall pay the
251     burial expenses in ordinary cases as established by rule.
252          (3) If a compensable accident results in the breaking of or loss of an employee's
253     artificial means or appliance including eyeglasses, the employer or insurance carrier shall
254     provide a replacement of the artificial means or appliance.
255          (4) An administrative law judge may require the employer or insurance carrier to
256     maintain the artificial means or appliances or provide the employee with a replacement of any
257     artificial means or appliance for the reason of breakage, wear and tear, deterioration, or
258     obsolescence.
259          (5) An administrative law judge may, in unusual cases, order, as the administrative law
260     judge considers just and proper, the payment of additional sums:
261          (a) for burial expenses; or
262          (b) to provide for artificial means or appliances.
263          Section 4. Section 34A-2-801 is amended to read:
264          34A-2-801. Initiating adjudicative proceedings -- Procedure for review of
265     administrative action.
266          (1) (a) To contest an action of the employee's employer or its insurance carrier
267     concerning a compensable industrial accident or occupational disease alleged by the employee
268     or a dependent any of the following shall file an application for hearing with the Division of
269     Adjudication:
270          (i) the employee;
271          (ii) a representative of the employee, the qualifications of whom are defined in rule by
272     the commission; or
273          (iii) a dependent as described in Section 34A-2-403.
274          (b) To appeal the imposition of a penalty or other administrative act imposed by the
275     division on the employer or its insurance carrier for failure to comply with this chapter or

276     Chapter 3, Utah Occupational Disease Act, any of the following shall file an application for
277     hearing with the Division of Adjudication:
278          (i) the employer;
279          (ii) the insurance carrier; or
280          (iii) a representative of either the employer or the insurance carrier, the qualifications
281     of whom are defined in rule by the commission.
282          (c) A person providing goods or services described in Subsections
283     34A-2-407[(11)](12) and 34A-3-108[(12)](13) may file an application for hearing in
284     accordance with Section 34A-2-407 or 34A-3-108.
285          (d) An attorney may file an application for hearing in accordance with Section
286     34A-1-309.
287          (2) (a) Unless all parties agree to the assignment in writing, the Division of
288     Adjudication may not assign the same administrative law judge to hear a claim under this
289     section by an injured employee if the administrative law judge previously heard a claim by the
290     same injured employee for a different injury or occupational disease.
291          (b) Unless all parties agree to the appointment in writing, an administrative law judge
292     may not appoint the same medical panel or individual panel member to evaluate a claim by an
293     injured employee if the medical panel or individual panel member previously evaluated a claim
294     by the same injured employee for a different injury or occupational disease.
295          (3) Unless a party in interest appeals the decision of an administrative law judge in
296     accordance with Subsection (4), the decision of an administrative law judge on an application
297     for hearing filed under Subsection (1) is a final order of the commission 30 days after the day
298     on which the decision is issued. An administrative law judge shall issue a decision by no later
299     than 60 days from the day on which the hearing is held under this part unless:
300          (a) the parties agree to a longer period of time; or
301          (b) a decision within the 60-day period is impracticable.
302          (4) (a) A party in interest may appeal the decision of an administrative law judge by
303     filing a motion for review with the Division of Adjudication within 30 days of the date the
304     decision is issued.
305          (b) Unless a party in interest to the appeal requests under Subsection (4)(c) that the
306     appeal be heard by the Appeals Board, the commissioner shall hear the review.

307          (c) A party in interest may request that an appeal be heard by the Appeals Board by
308     filing the request with the Division of Adjudication:
309          (i) as part of the motion for review; or
310          (ii) if requested by a party in interest who did not file a motion for review, within 20
311     days of the day on which the motion for review is filed with the Division of Adjudication.
312          (d) A case appealed to the Appeals Board shall be decided by the majority vote of the
313     Appeals Board.
314          (5) The Division of Adjudication shall maintain a record on appeal, including an
315     appeal docket showing the receipt and disposition of the appeals on review.
316          (6) Upon appeal, the commissioner or Appeals Board shall make its decision in
317     accordance with Section 34A-1-303. The commissioner or Appeals Board shall issue a
318     decision under this part by no later than 90 days from the day on which the motion for review is
319     filed unless:
320          (a) the parties agree to a longer period of time; or
321          (b) a decision within the 90-day period is impracticable.
322          (7) The commissioner or Appeals Board shall promptly notify the parties to a
323     proceeding before it of its decision, including its findings and conclusions.
324          (8) (a) Subject to Subsection (8)(b), the decision of the commissioner or Appeals
325     Board is final unless within 30 days after the date the decision is issued further appeal is
326     initiated under the provisions of this section or Title 63G, Chapter 4, Administrative
327     Procedures Act.
328          (b) In the case of an award of permanent total disability benefits under Section
329     34A-2-413, the decision of the commissioner or Appeals Board is a final order of the
330     commission unless set aside by the court of appeals.
331          (9) (a) Within 30 days after the day on which the decision of the commissioner or
332     Appeals Board is issued, an aggrieved party may secure judicial review by commencing an
333     action in the court of appeals against the commissioner or Appeals Board for the review of the
334     decision of the commissioner or Appeals Board.
335          (b) In an action filed under Subsection (9)(a):
336          (i) any other party to the proceeding before the commissioner or Appeals Board shall
337     be made a party; and

338          (ii) the commission shall be made a party.
339          (c) A party claiming to be aggrieved may seek judicial review only if the party exhausts
340     the party's remedies before the commission as provided by this section.
341          (d) At the request of the court of appeals, the commission shall certify and file with the
342     court all documents and papers and a transcript of all testimony taken in the matter together
343     with the decision of the commissioner or Appeals Board.
344          (10) (a) The commission shall make rules, in accordance with Title 63G, Chapter 3,
345     Utah Administrative Rulemaking Act, to facilitate timely completion of administrative actions
346     under this part.
347          (b) The commission shall monitor the time from filing of an application for a hearing
348     to issuance of a final order of the commission for cases brought under this part.
349          (c) The commission shall annually report to the Business and Labor Interim
350     Committee:
351          (i) the number of cases for which an application for hearing is filed under this part in
352     the previous calendar year;
353          (ii) the number of cases described in Subsection (10)(c)(i) for which the decision of the
354     administrative law judge was not issued within the 60-day period required by Subsection (3);
355          (iii) the number of cases described in Subsection (10)(c)(i) that are appealed to the
356     commissioner or Appeals Board for which the decision of the commissioner or Appeals Board
357     was not issued within the 90-day period required by Subsection (6);
358          (iv) the number of cases described in Subsection (10)(c)(i) for which a final order of
359     the commission is issued within 18 months of the day on which the application for hearing is
360     filed;
361          (v) the number of cases for which a final order of the commission is not issued within
362     18 months of the day on which the application for a hearing is filed; and
363          (vi) the reasons the cases described in Subsection (10)(c)(v) were not resolved within
364     18 months of the day on which the application for a hearing is filed.
365          Section 5. Section 34A-3-108 is amended to read:
366          34A-3-108. Reporting of occupational diseases -- Regulation of health care
367     providers.
368          (1) An employee sustaining an occupational disease, as defined in this chapter, arising

369     out of and in the course of employment shall provide notification to the employee's employer
370     promptly of the occupational disease. If the employee is unable to provide notification, the
371     employee's next of kin or attorney may provide notification of the occupational disease to the
372     employee's employer.
373          (2) (a) An employee who fails to notify the employee's employer or the division within
374     180 days after the cause of action arises is barred from a claim of benefits arising from the
375     occupational disease.
376          (b) The cause of action is considered to arise on the date the employee first:
377          (i) suffers disability from the occupational disease; and
378          (ii) knows, or in the exercise of reasonable diligence should have known, that the
379     occupational disease is caused by employment.
380          (3) The following constitute notification of an occupational disease:
381          (a) an employer's report filed with the:
382          (i) division; or
383          (ii) workers' compensation insurance carrier;
384          (b) a physician's injury report filed with the:
385          (i) division;
386          (ii) employer; or
387          (iii) workers' compensation insurance carrier;
388          (c) a workers' compensation insurance carrier's report to the division; or
389          (d) the payment of any medical or disability benefit by the employer or the employer's
390     workers' compensation insurance carrier.
391          (4) (a) An employer and the employer's workers' compensation insurance carrier, if
392     any, shall file a report in accordance with the rules described in Subsection (4)(b) of any
393     occupational disease resulting in:
394          (i) medical treatment;
395          (ii) loss of consciousness;
396          (iii) loss of work;
397          (iv) restriction of work; or
398          (v) transfer to another job.
399          (b) An employer or the employer's workers' compensation insurance carrier, if any,

400     shall file a report required under Subsection (4)(a) and any subsequent reports of a previously
401     reported occupational disease as may be required by the commission within the time limits and
402     in the manner established by rule by the commission made in accordance with Title 63G,
403     Chapter 3, Utah Administrative Rulemaking Act, under Subsection 34A-2-407(5).
404          (c) A report is not required:
405          (i) for a minor injury that requires first aid treatment only, unless a treating physician
406     files, or is required to file, the Physician's Initial Report of Work Injury or Occupational
407     Disease with the division;
408          (ii) for occupational diseases that manifest after the employee is no longer employed by
409     the employer with which the exposure occurred; or
410          (iii) when the employer is not aware of an exposure occasioned by the employment that
411     results in an occupational disease as defined by Section 34A-3-103.
412          (5) An employer or its workers' compensation insurance carrier, if any, shall provide
413     the employee with:
414          (a) a copy of the report submitted to the division; and
415          (b) a statement, as prepared by the division, of the employee's rights and
416     responsibilities related to the occupational disease.
417          (6) An employer shall maintain a record in a manner prescribed by the division of
418     occupational diseases resulting in:
419          (a) medical treatment;
420          (b) loss of consciousness;
421          (c) loss of work;
422          (d) restriction of work; or
423          (e) transfer to another job.
424          (7) An employer or a workers' compensation insurance carrier who refuses or neglects
425     to make a report, maintain a record, or file a report with the division as required by this section
426     is subject to citation and civil assessment in accordance with Subsection 34A-2-407(8).
427          (8) (a) Except as provided in Subsection (8)(c), a physician, surgeon, or other health
428     care provider attending an occupationally diseased employee shall:
429          (i) comply with the rules, including the schedule of fees, for services as adopted by the
430     commission;

431          (ii) make reports to the division at any and all times as required as to the condition and
432     treatment of an occupationally diseased employee or as to any other matter concerning
433     industrial cases being treated; and
434          (iii) comply with rules made under Section 34A-2-407.5.
435          (b) A physician, as defined in Section 34A-2-111, who is associated with, employed
436     by, or bills through a hospital is subject to Subsection (8)(a).
437          (c) A hospital is not subject to the requirements of Subsection (8)(a) except a hospital
438     is subject to rules made by the commission under Subsections 34A-2-407(9)(a)(ii) and (iii) and
439     Section 34A-2-407.5.
440          (d) The commission's schedule of fees may reasonably differentiate remuneration to be
441     paid to providers of health services based on:
442          (i) the severity of the employee's condition;
443          (ii) the nature of the treatment necessary; and
444          (iii) the facilities or equipment specially required to deliver that treatment.
445          (e) This Subsection (8) does not prohibit a contract with a provider of health services
446     relating to the pricing of goods and services.
447          (9) A copy of the physician's initial report shall be furnished to the:
448          (a) division;
449          (b) employee; and
450          (c) employer or its workers' compensation insurance carrier.
451          (10) A person subject to reporting under Subsection (8)(a)(ii) or Subsection
452     34A-2-407(9)(a)(iii) who refuses or neglects to make a report or comply with this section is
453     subject to a civil assessment in accordance with Subsection 34A-2-407(8).
454          (11) (a) As used in this Subsection (11):
455          (i) "Balance billing" means charging a person, on whose behalf a workers'
456     compensation insurance carrier or self-insured employer is obligated to pay medical benefits
457     under this chapter or Chapter 2, Workers' Compensation Act, for the difference between what
458     the workers' compensation insurance carrier or self-insured employer reimburses the hospital
459     for covered medical services and what the hospital charges for those covered medical services.
460          (ii) "Covered medical services" means medical services provided by a hospital that are
461     covered by workers' compensation medical benefits under this chapter or Chapter 2, Workers'

462     Compensation Act.
463          (iii) "Health benefit plan" means the same as that term is defined in Section
464     31A-22-619.6.
465          (iv) "Self-insured employer" means the same as that term is defined in Section
466     34A-2-201.5.
467          (b) Subject to Subsection (11)(d), a workers' compensation insurance carrier or
468     self-insured employer may contract with a hospital to establish reimbursement rates.
469          (c) Subject to Subsection (11)(d), a workers' compensation insurance carrier or
470     self-insured employer that is reimbursing a hospital that has not entered into a contract
471     described in Subsection (11)(b), shall reimburse the hospital for covered medical services at
472     85% of the billed hospital fees for the covered medical services.
473          (d) A hospital may not engage in balance billing.
474          (e) Covered services paid under a health benefit plan are subject to coordination of
475     benefits in accordance with Sections 31A-22-619.6 and 34A-2-213.
476          [(11)] (12) (a) An application for a hearing to resolve a dispute regarding an
477     occupational disease claim shall be filed with the Division of Adjudication.
478          (b) After the filing, a copy shall be forwarded by mail to:
479          (i) (A) the employer; or
480          (B) the employer's workers' compensation insurance carrier;
481          (ii) the applicant; and
482          (iii) the attorneys for the parties.
483          [(12)] (13) (a) Subject to appellate review under Section 34A-1-303, the commission
484     has exclusive jurisdiction to hear and determine:
485          (i) whether goods provided to or services rendered to an employee is compensable
486     pursuant to this chapter and Chapter 2, Workers' Compensation Act, including the following:
487          (A) medical, nurse, or hospital services;
488          (B) medicines; and
489          (C) artificial means, appliances, or prosthesis;
490          (ii) except for amounts charged or paid under Subsection (11), the reasonableness of
491     the amounts charged or paid for a good or service described in Subsection [(12)] (13)(a)(i); and
492          (iii) collection issues related to a good or service described in Subsection [(12)]

493     (13)(a)(i).
494          (b) Except as provided in Subsection [(12)] (13)(a), Subsection 34A-2-211(6), or
495     Section 34A-2-212, a person may not maintain a cause of action in any forum within this state
496     other than the commission for collection or payment of goods or services described in
497     Subsection [(12)] (13)(a) that are compensable under this chapter or Chapter 2, Workers'
498     Compensation Act.






Legislative Review Note
Office of Legislative Research and General Counsel