Utah Code 31A-45-301. Written contracts — Limited liability of enrollee — Provider claim disputes — Leased networks
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(1) A managed care organization may not contract with a health care provider for treatment of illness or injury unless the health care provider is licensed to perform that treatment. Every contract between a managed care organization and a network provider shall be in writing and shall set forth that if the managed care organization:
Terms Used In Utah Code 31A-45-301
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: includes an insured. See Utah Code 31A-1-301
- Filing: when used as a noun, means an item required to be filed with the department including:(70)(a) a policy;(70)(b) a rate;(70)(c) a form;(70)(d) a document;(70)(e) a plan;(70)(f) a manual;(70)(g) an application;(70)(h) a report;(70)(i) a certificate;(70)(j) an endorsement;(70)(k) an actuarial certification;(70)(l) a licensee annual statement;(70)(m) a licensee renewal application;(70)(n) an advertisement;(70)(o) a binder; or(70)(p) an outline of coverage. See Utah Code 31A-1-301
- 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- Health care provider: means the same as that term is defined in Section
78B-3-403 . See Utah Code 31A-1-301- insolvent: means that:
(95)(a) an insurer is unable to pay the insurer's obligations as the obligations are due;(95)(b) an insurer's total adjusted capital is less than the insurer's mandatory control level RBC under Subsection31A-17-601 (8)(c); or(95)(c) an insurer's admitted assets are less than the insurer's liabilities. See Utah Code 31A-1-301- Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
- Managed care organization: means :
(2)(a) a managed care organization as that term is defined in Section 31A-1-301; and(2)(b) a third party administrator as that term is defined in Section 31A-1-301. See Utah Code 31A-45-102- Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. See Utah Code 31A-1-301
- Person: includes :
(146)(a) an individual;(146)(b) a partnership;(146)(c) a corporation;(146)(d) an incorporated or unincorporated association;(146)(e) a joint stock company;(146)(f) a trust;(146)(g) a limited liability company;(146)(h) a reciprocal;(146)(i) a syndicate; or(146)(j) another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301- Writing: includes :
(48)(a) printing;(48)(b) handwriting; and(48)(c) information stored in an electronic or other medium if the information is retrievable in a perceivable format. See Utah Code 68-3-12.5(1)(a) fails to pay for health care services as set forth in the contract, the enrollee is not liable to the health care provider for any sums owed by the managed care organization; and(1)(b) becomes insolvent, the rehabilitator or liquidator may require the network provider to:(1)(b)(i) continue to provide health care services under the contract between the network provider and the managed care organization until the earlier of:(1)(b)(i)(A) 90 days after the date of the filing of a petition for rehabilitation or a petition for liquidation; or(1)(b)(i)(B) the date the term of the contract ends; and(1)(b)(ii) subject to Subsection (3), reduce the fees the network provider is otherwise entitled to receive from the managed care organization under the contract between the network provider and the managed care organization during the time period described in Subsection (1)(b)(i).(2) If the conditions of Subsection (3) are met, the network provider:(2)(a) shall accept the reduced payment as payment in full; and(2)(b) as provided in Subsection (1)(a), may not collect additional amounts from the insolvent managed care organization’s enrollee, except as may be owed under Subsection (3)(b).(3) Notwithstanding Subsection (1)(b)(ii):(3)(a) the rehabilitator or liquidator may not reduce a fee to less than 75% of the regular fee set forth in the network provider contract; and(3)(b) the enrollee shall continue to pay the same copayments, deductibles, and other payments for services received from the network provider that the enrollee was required to pay before the filing of:(3)(b)(i) the petition for rehabilitation; or(3)(b)(ii) the petition for liquidation.(4) A network provider may not collect or attempt to collect from the enrollee sums owed by the managed care organization or the amount of the regular fee reduction authorized under Subsection (1)(b)(ii) if the network provider contract:(4)(a) is not in writing as required in Subsection (1); or(4)(b) fails to contain the language required by Subsection (1).(5)(5)(a) A person listed in Subsection (5)(b) may not bill or maintain any action at law against an enrollee to collect:(5)(a)(i) sums owed by the organization; or(5)(a)(ii) the amount of the regular fee reduction authorized under Subsection (1)(b)(ii).(5)(b) Subsection (5)(a) applies to:(5)(b)(i) a network provider;(5)(b)(ii) an agent;(5)(b)(iii) a trustee; or(5)(b)(iv) an assignee of a person described in Subsections (5)(b)(i) through (iii).(5)(c) In any dispute involving a network provider’s claim for reimbursement, the network provider’s claim shall be determined in accordance with applicable law, the network provider contract, the enrollee contract, and the managed care organization’s written payment policies in effect at the time services were rendered.(5)(d) If the parties are unable to resolve their dispute, the matter shall be subject to binding arbitration by a jointly selected arbitrator. Each party shall bear its own expense except that the cost of the jointly selected arbitrator shall be equally shared. This Subsection (5)(d) does not apply to the claim of a general acute hospital to the extent the claim is inconsistent with the hospital’s provider agreement.(5)(e) A managed care organization may not penalize a network provider solely for pursuing a claims dispute or otherwise demanding payment for a sum believed owing.(6) If a managed care organization permits another private entity with which the managed care organization does not share common ownership or control to use or otherwise lease one or more of the organization’s networks that include network providers, the managed care organization shall ensure, at a minimum, that the entity pays the network providers included in the managed care organization’s network in accordance with the same fee schedule and general payment policies as the managed care organization would pay for those network providers, unless payment for services is governed by a public program’s fee schedule. - Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment: