State Codes and Statutes
Statutes > Utah > Title-31a > Chapter-08 > 31a-8-40731A-8-407. Written contracts -- Limited liability of enrollee -- Provider claimdisputes -- Leased networks.
(1) (a) Every contract between an organization and a participating provider of health careservices 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 beliable to the provider for any sums owed by the organization; and
(ii) becomes insolvent, the rehabilitator or liquidator may require the participatingprovider of health care services to:
(A) continue to provide health care services under the contract between the participatingprovider and the organization until the earlier of:
(I) 90 days after the date of the filing of a petition for rehabilitation or the petition forliquidation; or
(II) the date the term of the contract ends; and
(B) subject to Subsection (1)(c), reduce the fees the participating provider is otherwiseentitled to receive from the organization under the contract between the participating providerand 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'senrollee.
(c) Notwithstanding Subsection (1)(a)(ii)(B):
(i) the rehabilitator or liquidator may not reduce a fee to less than 75% of the regular feeset forth in the participating provider contract; and
(ii) the enrollee shall continue to pay the same copayments, deductibles, and otherpayments for services received from the participating provider that the enrollee was required topay 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 sumsowed 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 lawagainst 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 bedetermined in accordance with applicable law, the provider contract, the subscriber contract, andthe 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 bindingarbitration by a jointly selected arbitrator. Each party is to bear its own expense except the costof the jointly selected arbitrator shall be equally shared. This Subsection (3)(d) does not apply tothe claim of a general acute hospital to the extent it is inconsistent with the hospital's provideragreement.
(e) An organization may not penalize a provider solely for pursuing a claims dispute orotherwise demanding payment for a sum believed owing.
(4) If an organization permits another private entity with which it does not share commonownership or control to use or otherwise lease one or more of the organization's networks thatinclude participating providers, the organization shall ensure, at a minimum, that the entity paysparticipating providers in accordance with the same fee schedule and general payment policies asthe organization would for that network unless payment for services is governed by a publicprogram's fee schedule.
Amended by Chapter 3, 2005 Special Session 1
