State Codes and Statutes

Statutes > Utah > Title-31a > Chapter-22 > 31a-22-617

31A-22-617. Preferred provider contract provisions.
Health insurance policies may provide for insureds to receive services or reimbursementunder the policies in accordance with preferred health care provider contracts as follows:
(1) Subject to restrictions under this section, any insurer or third party administrator mayenter into contracts with health care providers as defined in Section 78B-3-403 under which thehealth care providers agree to supply services, at prices specified in the contracts, to personsinsured by an insurer.
(a) (i) A health care provider contract may require the health care provider to accept thespecified payment as payment in full, relinquishing the right to collect additional amounts fromthe insured person.
(ii) 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 insurer's written payment policies in effect at the time services were rendered.
(iii) If the parties are unable to resolve their dispute, the matter shall be subject tobinding arbitration by a jointly selected arbitrator. Each party is to bear its own expense exceptthe cost of the jointly selected arbitrator shall be equally shared. This Subsection (1)(a)(iii) doesnot apply to the claim of a general acute hospital to the extent it is inconsistent with the hospital'sprovider agreement.
(iv) An organization may not penalize a provider solely for pursuing a claims dispute orotherwise demanding payment for a sum believed owing.
(v) If an insurer permits another entity with which it does not share common ownershipor control to use or otherwise lease one or more of the organization's networks of participatingproviders, the organization shall ensure, at a minimum, that the entity pays participatingproviders in accordance with the same fee schedule and general payment policies as theorganization would for that network.
(b) The insurance contract may reward the insured for selection of preferred health careproviders by:
(i) reducing premium rates;
(ii) reducing deductibles;
(iii) coinsurance;
(iv) other copayments; or
(v) any other reasonable manner.
(c) If the insurer is a managed care organization, as defined in Subsection31A-27a-403(1)(f):
(i) the insurance contract and the health care provider contract shall provide that in theevent the managed care organization becomes insolvent, the rehabilitator or liquidator may:
(A) require the health care provider to continue to provide health care services under thecontract 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)(v), reduce the fees the provider is otherwise entitled toreceive from the managed care organization during the time period described in Subsection(1)(c)(i)(A);
(ii) the provider is required to:

(A) accept the reduced payment under Subsection (1)(c)(i)(B) as payment in full; and
(B) relinquish the right to collect additional amounts from the insolvent managed careorganization's enrollee, as defined in Subsection 31A-27a-403(1)(b);
(iii) if the contract between the health care provider and the managed care organizationhas not been reduced to writing, or the contract fails to contain the language required bySubsection (1)(c)(i), the provider may not collect or attempt to collect from the enrollee:
(A) sums owed by the insolvent managed care organization; or
(B) the amount of the regular fee reduction authorized under Subsection (1)(c)(i)(B);
(iv) the following may not bill or maintain any action at law against an enrollee to collectsums owed by the insolvent managed care organization or the amount of the regular fee reductionauthorized under Subsection (1)(c)(i)(B):
(A) a provider;
(B) an agent;
(C) a trustee; or
(D) an assignee of a person described in Subsections (1)(c)(iv)(A) through (C); and
(v) notwithstanding Subsection (1)(c)(i):
(A) a rehabilitator or liquidator may not reduce a fee by less than 75% of the provider'sregular fee set forth in the contract; and
(B) the enrollee shall continue to pay the copayments, deductibles, and other paymentsfor services received from the provider that the enrollee was required to pay before the filing of:
(I) a petition for rehabilitation; or
(II) a petition for liquidation.
(2) (a) Subject to Subsections (2)(b) through (2)(f), an insurer using preferred health careprovider contracts shall pay for the services of health care providers not under the contract,unless the illnesses or injuries treated by the health care provider are not within the scope of theinsurance contract. As used in this section, "class of health care providers" means all health careproviders licensed or licensed and certified by the state within the same professional, trade,occupational, or facility licensure or licensure and certification category established pursuant toTitles 26, Utah Health Code and 58, Occupations and Professions.
(b) (i) Until July 1, 2012, when the insured receives services from a health care providernot under contract, the insurer shall reimburse the insured for at least 75% of the average amountpaid by the insurer for comparable services of preferred health care providers who are membersof the same class of health care providers.
(ii) Notwithstanding Subsection (2)(b)(i), an insurer may offer a health plan thatcomplies with the provisions of Subsection 31A-22-618.5(3).
(iii) The commissioner may adopt a rule dealing with the determination of whatconstitutes 75% of the average amount paid by the insurer under Subsection (2)(b)(i) forcomparable services of preferred health care providers who are members of the same class ofhealth care providers.
(c) When reimbursing for services of health care providers not under contract, the insurermay make direct payment to the insured.
(d) Notwithstanding Subsection (2)(b), an insurer using preferred health care providercontracts may impose a deductible on coverage of health care providers not under contract.
(e) When selecting health care providers with whom to contract under Subsection (1), aninsurer may not unfairly discriminate between classes of health care providers, but may

discriminate within a class of health care providers, subject to Subsection (7).
(f) For purposes of this section, unfair discrimination between classes of health careproviders shall include:
(i) refusal to contract with class members in reasonable proportion to the number ofinsureds covered by the insurer and the expected demand for services from class members; and
(ii) refusal to cover procedures for one class of providers that are:
(A) commonly utilized by members of the class of health care providers for the treatmentof illnesses, injuries, or conditions;
(B) otherwise covered by the insurer; and
(C) within the scope of practice of the class of health care providers.
(3) Before the insured consents to the insurance contract, the insurer shall fully discloseto the insured that it has entered into preferred health care provider contracts. The insurer shallprovide sufficient detail on the preferred health care provider contracts to permit the insured toagree to the terms of the insurance contract. The insurer shall provide at least the followinginformation:
(a) a list of the health care providers under contract and if requested their businesslocations and specialties;
(b) a description of the insured benefits, including any deductibles, coinsurance, or othercopayments;
(c) a description of the quality assurance program required under Subsection (4); and
(d) a description of the adverse benefit determination procedures required underSubsection (5).
(4) (a) An insurer using preferred health care provider contracts shall maintain a qualityassurance program for assuring that the care provided by the health care providers under contractmeets prevailing standards in the state.
(b) The commissioner in consultation with the executive director of the Department ofHealth may designate qualified persons to perform an audit of the quality assurance program. The auditors shall have full access to all records of the organization and its health care providers,including medical records of individual patients.
(c) The information contained in the medical records of individual patients shall remainconfidential. All information, interviews, reports, statements, memoranda, or other datafurnished for purposes of the audit and any findings or conclusions of the auditors are privileged. The information is not subject to discovery, use, or receipt in evidence in any legal proceedingexcept hearings before the commissioner concerning alleged violations of this section.
(5) An insurer using preferred health care provider contracts shall provide a reasonableprocedure for resolving complaints and adverse benefit determinations initiated by the insuredsand health care providers.
(6) An insurer may not contract with a health care provider for treatment of illness orinjury unless the health care provider is licensed to perform that treatment.
(7) (a) A health care provider or insurer may not discriminate against a preferred healthcare provider for agreeing to a contract under Subsection (1).
(b) Any health care provider licensed to treat any illness or injury within the scope of thehealth care provider's practice, who is willing and able to meet the terms and conditionsestablished by the insurer for designation as a preferred health care provider, shall be able toapply for and receive the designation as a preferred health care provider. Contract terms and

conditions may include reasonable limitations on the number of designated preferred health careproviders based upon substantial objective and economic grounds, or expected use of particularservices based upon prior provider-patient profiles.
(8) Upon the written request of a provider excluded from a provider contract, thecommissioner may hold a hearing to determine if the insurer's exclusion of the provider is basedon the criteria set forth in Subsection (7)(b).
(9) Insurers are subject to the provisions of Sections 31A-22-613.5, 31A-22-614.5, and31A-22-618.
(10) Nothing in this section is to be construed as to require an insurer to offer a certainbenefit or service as part of a health benefit plan.
(11) This section does not apply to catastrophic mental health coverage provided inaccordance with Section 31A-22-625.

Amended by Chapter 12, 2009 General Session

State Codes and Statutes

Statutes > Utah > Title-31a > Chapter-22 > 31a-22-617

31A-22-617. Preferred provider contract provisions.
Health insurance policies may provide for insureds to receive services or reimbursementunder the policies in accordance with preferred health care provider contracts as follows:
(1) Subject to restrictions under this section, any insurer or third party administrator mayenter into contracts with health care providers as defined in Section 78B-3-403 under which thehealth care providers agree to supply services, at prices specified in the contracts, to personsinsured by an insurer.
(a) (i) A health care provider contract may require the health care provider to accept thespecified payment as payment in full, relinquishing the right to collect additional amounts fromthe insured person.
(ii) 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 insurer's written payment policies in effect at the time services were rendered.
(iii) If the parties are unable to resolve their dispute, the matter shall be subject tobinding arbitration by a jointly selected arbitrator. Each party is to bear its own expense exceptthe cost of the jointly selected arbitrator shall be equally shared. This Subsection (1)(a)(iii) doesnot apply to the claim of a general acute hospital to the extent it is inconsistent with the hospital'sprovider agreement.
(iv) An organization may not penalize a provider solely for pursuing a claims dispute orotherwise demanding payment for a sum believed owing.
(v) If an insurer permits another entity with which it does not share common ownershipor control to use or otherwise lease one or more of the organization's networks of participatingproviders, the organization shall ensure, at a minimum, that the entity pays participatingproviders in accordance with the same fee schedule and general payment policies as theorganization would for that network.
(b) The insurance contract may reward the insured for selection of preferred health careproviders by:
(i) reducing premium rates;
(ii) reducing deductibles;
(iii) coinsurance;
(iv) other copayments; or
(v) any other reasonable manner.
(c) If the insurer is a managed care organization, as defined in Subsection31A-27a-403(1)(f):
(i) the insurance contract and the health care provider contract shall provide that in theevent the managed care organization becomes insolvent, the rehabilitator or liquidator may:
(A) require the health care provider to continue to provide health care services under thecontract 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)(v), reduce the fees the provider is otherwise entitled toreceive from the managed care organization during the time period described in Subsection(1)(c)(i)(A);
(ii) the provider is required to:

(A) accept the reduced payment under Subsection (1)(c)(i)(B) as payment in full; and
(B) relinquish the right to collect additional amounts from the insolvent managed careorganization's enrollee, as defined in Subsection 31A-27a-403(1)(b);
(iii) if the contract between the health care provider and the managed care organizationhas not been reduced to writing, or the contract fails to contain the language required bySubsection (1)(c)(i), the provider may not collect or attempt to collect from the enrollee:
(A) sums owed by the insolvent managed care organization; or
(B) the amount of the regular fee reduction authorized under Subsection (1)(c)(i)(B);
(iv) the following may not bill or maintain any action at law against an enrollee to collectsums owed by the insolvent managed care organization or the amount of the regular fee reductionauthorized under Subsection (1)(c)(i)(B):
(A) a provider;
(B) an agent;
(C) a trustee; or
(D) an assignee of a person described in Subsections (1)(c)(iv)(A) through (C); and
(v) notwithstanding Subsection (1)(c)(i):
(A) a rehabilitator or liquidator may not reduce a fee by less than 75% of the provider'sregular fee set forth in the contract; and
(B) the enrollee shall continue to pay the copayments, deductibles, and other paymentsfor services received from the provider that the enrollee was required to pay before the filing of:
(I) a petition for rehabilitation; or
(II) a petition for liquidation.
(2) (a) Subject to Subsections (2)(b) through (2)(f), an insurer using preferred health careprovider contracts shall pay for the services of health care providers not under the contract,unless the illnesses or injuries treated by the health care provider are not within the scope of theinsurance contract. As used in this section, "class of health care providers" means all health careproviders licensed or licensed and certified by the state within the same professional, trade,occupational, or facility licensure or licensure and certification category established pursuant toTitles 26, Utah Health Code and 58, Occupations and Professions.
(b) (i) Until July 1, 2012, when the insured receives services from a health care providernot under contract, the insurer shall reimburse the insured for at least 75% of the average amountpaid by the insurer for comparable services of preferred health care providers who are membersof the same class of health care providers.
(ii) Notwithstanding Subsection (2)(b)(i), an insurer may offer a health plan thatcomplies with the provisions of Subsection 31A-22-618.5(3).
(iii) The commissioner may adopt a rule dealing with the determination of whatconstitutes 75% of the average amount paid by the insurer under Subsection (2)(b)(i) forcomparable services of preferred health care providers who are members of the same class ofhealth care providers.
(c) When reimbursing for services of health care providers not under contract, the insurermay make direct payment to the insured.
(d) Notwithstanding Subsection (2)(b), an insurer using preferred health care providercontracts may impose a deductible on coverage of health care providers not under contract.
(e) When selecting health care providers with whom to contract under Subsection (1), aninsurer may not unfairly discriminate between classes of health care providers, but may

discriminate within a class of health care providers, subject to Subsection (7).
(f) For purposes of this section, unfair discrimination between classes of health careproviders shall include:
(i) refusal to contract with class members in reasonable proportion to the number ofinsureds covered by the insurer and the expected demand for services from class members; and
(ii) refusal to cover procedures for one class of providers that are:
(A) commonly utilized by members of the class of health care providers for the treatmentof illnesses, injuries, or conditions;
(B) otherwise covered by the insurer; and
(C) within the scope of practice of the class of health care providers.
(3) Before the insured consents to the insurance contract, the insurer shall fully discloseto the insured that it has entered into preferred health care provider contracts. The insurer shallprovide sufficient detail on the preferred health care provider contracts to permit the insured toagree to the terms of the insurance contract. The insurer shall provide at least the followinginformation:
(a) a list of the health care providers under contract and if requested their businesslocations and specialties;
(b) a description of the insured benefits, including any deductibles, coinsurance, or othercopayments;
(c) a description of the quality assurance program required under Subsection (4); and
(d) a description of the adverse benefit determination procedures required underSubsection (5).
(4) (a) An insurer using preferred health care provider contracts shall maintain a qualityassurance program for assuring that the care provided by the health care providers under contractmeets prevailing standards in the state.
(b) The commissioner in consultation with the executive director of the Department ofHealth may designate qualified persons to perform an audit of the quality assurance program. The auditors shall have full access to all records of the organization and its health care providers,including medical records of individual patients.
(c) The information contained in the medical records of individual patients shall remainconfidential. All information, interviews, reports, statements, memoranda, or other datafurnished for purposes of the audit and any findings or conclusions of the auditors are privileged. The information is not subject to discovery, use, or receipt in evidence in any legal proceedingexcept hearings before the commissioner concerning alleged violations of this section.
(5) An insurer using preferred health care provider contracts shall provide a reasonableprocedure for resolving complaints and adverse benefit determinations initiated by the insuredsand health care providers.
(6) An insurer may not contract with a health care provider for treatment of illness orinjury unless the health care provider is licensed to perform that treatment.
(7) (a) A health care provider or insurer may not discriminate against a preferred healthcare provider for agreeing to a contract under Subsection (1).
(b) Any health care provider licensed to treat any illness or injury within the scope of thehealth care provider's practice, who is willing and able to meet the terms and conditionsestablished by the insurer for designation as a preferred health care provider, shall be able toapply for and receive the designation as a preferred health care provider. Contract terms and

conditions may include reasonable limitations on the number of designated preferred health careproviders based upon substantial objective and economic grounds, or expected use of particularservices based upon prior provider-patient profiles.
(8) Upon the written request of a provider excluded from a provider contract, thecommissioner may hold a hearing to determine if the insurer's exclusion of the provider is basedon the criteria set forth in Subsection (7)(b).
(9) Insurers are subject to the provisions of Sections 31A-22-613.5, 31A-22-614.5, and31A-22-618.
(10) Nothing in this section is to be construed as to require an insurer to offer a certainbenefit or service as part of a health benefit plan.
(11) This section does not apply to catastrophic mental health coverage provided inaccordance with Section 31A-22-625.

Amended by Chapter 12, 2009 General Session


State Codes and Statutes


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State Codes and Statutes

Statutes > Utah > Title-31a > Chapter-22 > 31a-22-617

31A-22-617. Preferred provider contract provisions.
Health insurance policies may provide for insureds to receive services or reimbursementunder the policies in accordance with preferred health care provider contracts as follows:
(1) Subject to restrictions under this section, any insurer or third party administrator mayenter into contracts with health care providers as defined in Section 78B-3-403 under which thehealth care providers agree to supply services, at prices specified in the contracts, to personsinsured by an insurer.
(a) (i) A health care provider contract may require the health care provider to accept thespecified payment as payment in full, relinquishing the right to collect additional amounts fromthe insured person.
(ii) 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 insurer's written payment policies in effect at the time services were rendered.
(iii) If the parties are unable to resolve their dispute, the matter shall be subject tobinding arbitration by a jointly selected arbitrator. Each party is to bear its own expense exceptthe cost of the jointly selected arbitrator shall be equally shared. This Subsection (1)(a)(iii) doesnot apply to the claim of a general acute hospital to the extent it is inconsistent with the hospital'sprovider agreement.
(iv) An organization may not penalize a provider solely for pursuing a claims dispute orotherwise demanding payment for a sum believed owing.
(v) If an insurer permits another entity with which it does not share common ownershipor control to use or otherwise lease one or more of the organization's networks of participatingproviders, the organization shall ensure, at a minimum, that the entity pays participatingproviders in accordance with the same fee schedule and general payment policies as theorganization would for that network.
(b) The insurance contract may reward the insured for selection of preferred health careproviders by:
(i) reducing premium rates;
(ii) reducing deductibles;
(iii) coinsurance;
(iv) other copayments; or
(v) any other reasonable manner.
(c) If the insurer is a managed care organization, as defined in Subsection31A-27a-403(1)(f):
(i) the insurance contract and the health care provider contract shall provide that in theevent the managed care organization becomes insolvent, the rehabilitator or liquidator may:
(A) require the health care provider to continue to provide health care services under thecontract 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)(v), reduce the fees the provider is otherwise entitled toreceive from the managed care organization during the time period described in Subsection(1)(c)(i)(A);
(ii) the provider is required to:

(A) accept the reduced payment under Subsection (1)(c)(i)(B) as payment in full; and
(B) relinquish the right to collect additional amounts from the insolvent managed careorganization's enrollee, as defined in Subsection 31A-27a-403(1)(b);
(iii) if the contract between the health care provider and the managed care organizationhas not been reduced to writing, or the contract fails to contain the language required bySubsection (1)(c)(i), the provider may not collect or attempt to collect from the enrollee:
(A) sums owed by the insolvent managed care organization; or
(B) the amount of the regular fee reduction authorized under Subsection (1)(c)(i)(B);
(iv) the following may not bill or maintain any action at law against an enrollee to collectsums owed by the insolvent managed care organization or the amount of the regular fee reductionauthorized under Subsection (1)(c)(i)(B):
(A) a provider;
(B) an agent;
(C) a trustee; or
(D) an assignee of a person described in Subsections (1)(c)(iv)(A) through (C); and
(v) notwithstanding Subsection (1)(c)(i):
(A) a rehabilitator or liquidator may not reduce a fee by less than 75% of the provider'sregular fee set forth in the contract; and
(B) the enrollee shall continue to pay the copayments, deductibles, and other paymentsfor services received from the provider that the enrollee was required to pay before the filing of:
(I) a petition for rehabilitation; or
(II) a petition for liquidation.
(2) (a) Subject to Subsections (2)(b) through (2)(f), an insurer using preferred health careprovider contracts shall pay for the services of health care providers not under the contract,unless the illnesses or injuries treated by the health care provider are not within the scope of theinsurance contract. As used in this section, "class of health care providers" means all health careproviders licensed or licensed and certified by the state within the same professional, trade,occupational, or facility licensure or licensure and certification category established pursuant toTitles 26, Utah Health Code and 58, Occupations and Professions.
(b) (i) Until July 1, 2012, when the insured receives services from a health care providernot under contract, the insurer shall reimburse the insured for at least 75% of the average amountpaid by the insurer for comparable services of preferred health care providers who are membersof the same class of health care providers.
(ii) Notwithstanding Subsection (2)(b)(i), an insurer may offer a health plan thatcomplies with the provisions of Subsection 31A-22-618.5(3).
(iii) The commissioner may adopt a rule dealing with the determination of whatconstitutes 75% of the average amount paid by the insurer under Subsection (2)(b)(i) forcomparable services of preferred health care providers who are members of the same class ofhealth care providers.
(c) When reimbursing for services of health care providers not under contract, the insurermay make direct payment to the insured.
(d) Notwithstanding Subsection (2)(b), an insurer using preferred health care providercontracts may impose a deductible on coverage of health care providers not under contract.
(e) When selecting health care providers with whom to contract under Subsection (1), aninsurer may not unfairly discriminate between classes of health care providers, but may

discriminate within a class of health care providers, subject to Subsection (7).
(f) For purposes of this section, unfair discrimination between classes of health careproviders shall include:
(i) refusal to contract with class members in reasonable proportion to the number ofinsureds covered by the insurer and the expected demand for services from class members; and
(ii) refusal to cover procedures for one class of providers that are:
(A) commonly utilized by members of the class of health care providers for the treatmentof illnesses, injuries, or conditions;
(B) otherwise covered by the insurer; and
(C) within the scope of practice of the class of health care providers.
(3) Before the insured consents to the insurance contract, the insurer shall fully discloseto the insured that it has entered into preferred health care provider contracts. The insurer shallprovide sufficient detail on the preferred health care provider contracts to permit the insured toagree to the terms of the insurance contract. The insurer shall provide at least the followinginformation:
(a) a list of the health care providers under contract and if requested their businesslocations and specialties;
(b) a description of the insured benefits, including any deductibles, coinsurance, or othercopayments;
(c) a description of the quality assurance program required under Subsection (4); and
(d) a description of the adverse benefit determination procedures required underSubsection (5).
(4) (a) An insurer using preferred health care provider contracts shall maintain a qualityassurance program for assuring that the care provided by the health care providers under contractmeets prevailing standards in the state.
(b) The commissioner in consultation with the executive director of the Department ofHealth may designate qualified persons to perform an audit of the quality assurance program. The auditors shall have full access to all records of the organization and its health care providers,including medical records of individual patients.
(c) The information contained in the medical records of individual patients shall remainconfidential. All information, interviews, reports, statements, memoranda, or other datafurnished for purposes of the audit and any findings or conclusions of the auditors are privileged. The information is not subject to discovery, use, or receipt in evidence in any legal proceedingexcept hearings before the commissioner concerning alleged violations of this section.
(5) An insurer using preferred health care provider contracts shall provide a reasonableprocedure for resolving complaints and adverse benefit determinations initiated by the insuredsand health care providers.
(6) An insurer may not contract with a health care provider for treatment of illness orinjury unless the health care provider is licensed to perform that treatment.
(7) (a) A health care provider or insurer may not discriminate against a preferred healthcare provider for agreeing to a contract under Subsection (1).
(b) Any health care provider licensed to treat any illness or injury within the scope of thehealth care provider's practice, who is willing and able to meet the terms and conditionsestablished by the insurer for designation as a preferred health care provider, shall be able toapply for and receive the designation as a preferred health care provider. Contract terms and

conditions may include reasonable limitations on the number of designated preferred health careproviders based upon substantial objective and economic grounds, or expected use of particularservices based upon prior provider-patient profiles.
(8) Upon the written request of a provider excluded from a provider contract, thecommissioner may hold a hearing to determine if the insurer's exclusion of the provider is basedon the criteria set forth in Subsection (7)(b).
(9) Insurers are subject to the provisions of Sections 31A-22-613.5, 31A-22-614.5, and31A-22-618.
(10) Nothing in this section is to be construed as to require an insurer to offer a certainbenefit or service as part of a health benefit plan.
(11) This section does not apply to catastrophic mental health coverage provided inaccordance with Section 31A-22-625.

Amended by Chapter 12, 2009 General Session


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