Utah Code 31A-22-628. Standing referral to a specialist
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(1) With respect to a health insurance policy or managed care organization contract that does not allow an insured to have direct access to a health care specialist, the insurer shall establish and implement a procedure by which an insured may obtain a standing referral to a health care specialist.
Terms Used In Utah Code 31A-22-628
- Contract: A legal written agreement that becomes binding when signed.
- Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment:(83)(a) a professional service;(83)(b) a personal service;(83)(c) a facility;(83)(d) equipment;(83)(e) a device;(83)(f) supplies; or(83)(g) medicine. See Utah Code 31A-1-301
- Insurance: includes :
(96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;(96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and(96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
(103)(a)(i) a policyholder;(103)(a)(ii) a subscriber;(103)(a)(iii) a member; and(103)(a)(iv) a beneficiary. See Utah Code 31A-1-301- Managed care organization: means a person:
(122)(a) licensed as a health maintenance organization under Chapter 8, Health Maintenance Organizations and Limited Health Plans; or(122)(b)(122)(b)(i) licensed under:(122)(b)(i)(A) Chapter 5, Domestic Stock and Mutual Insurance Corporations;(122)(b)(i)(B) Chapter 7, Nonprofit Health Service Insurance Corporations; or(122)(b)(i)(C) Chapter 14, Foreign Insurers; and(122)(b)(ii) that requires an enrollee to use, or offers incentives, including financial incentives, for an enrollee to use, network providers. See Utah Code 31A-1-301- Policy: includes a service contract issued by:
(150)(b)(i) a motor club under Chapter 11, Motor Clubs;(150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and(150)(b)(iii) a corporation licensed under:(150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or(150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301(2) The procedure established under Subsection (1):(2)(a) shall provide for a standing referral to a specialist if the insured’s primary care provider determines, in consultation with the specialist, that the insured needs continuing care from the specialist; and(2)(b) may require the insurer’s approval of a treatment plan designed by the specialist, in consultation with the primary care provider and the insured, which may include:(2)(b)(i) a limit on the number of visits to the specialist;(2)(b)(ii) a time limit on the duration of the referral; and(2)(b)(iii) mandatory updates on the insured’s condition. - Insurance: includes :