Utah Code 26B-3-1004. Health insurance entity — Duties related to state claims for Medicaid payment or recovery
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(1) As a condition of doing business in the state, a health insurance entity shall:
Terms Used In Utah Code 26B-3-1004
- Claim: means :(3)(a) a request or demand for payment; or(3)(b) a cause of action for money or damages arising under any law. See Utah Code 26B-3-1001
- Dependent: A person dependent for support upon another.
- Health insurance entity: means :
(5)(a) an insurer;(5)(b) a person who administers, manages, provides, offers, sells, carries, or underwrites health insurance, as defined in Section 31A-1-301;(5)(c) a self-insured plan;(5)(d) a group health plan, as defined in Subsection 607(1) of the federal Employee Retirement Income Security Act of 1974;(5)(e) a service benefit plan;(5)(f) a managed care organization;(5)(g) a pharmacy benefit manager;(5)(h) an employee welfare benefit plan; or(5)(i) a person who is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service. See Utah Code 26B-3-1001- Medical assistance: means :
(8)(a) all funds expended for the benefit of a recipient under this chapter or Titles XVIII and XIX, federal Social Security Act; and(8)(b) any other services provided for the benefit of a recipient by a prepaid health care delivery system under contract with the department. See Utah Code 26B-3-1001- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
- State plan: means the state Medicaid program as enacted in accordance with Title XIX, federal Social Security Act. See Utah Code 26B-3-1001
(1)(a) with respect to an individual who is eligible for, or is provided, medical assistance under the state plan, upon the request of the department, provide information to determine:(1)(a)(i) during what period the individual, or the spouse or dependent of the individual, may be or may have been, covered by the health insurance entity; and(1)(a)(ii) the nature of the coverage that is or was provided by the health insurance entity described in Subsection (1)(a), including the name, address, and identifying number of the plan;(1)(b) accept the state’s right of recovery and the assignment to the state of any right of an individual to payment from a party for an item or service for which payment has been made under the state plan;(1)(c) respond within 60 days to any inquiry by the department regarding a claim for payment for any health care item or service that is submitted no later than three years after the day on which the health care item or service is provided;(1)(d) not deny a claim submitted by the department solely on the basis of the date of submission of the claim, the type or format of the claim form, or failure to present proper documentation at the point-of-sale that is the basis for the claim, if:(1)(d)(i) the claim is submitted no later than three years after the day on which the item or service is furnished; and(1)(d)(ii) any action by the department to enforce the rights of the state with respect to the claim is commenced no later than six years after the day on which the claim is submitted; and(1)(e) not deny a claim submitted by the department or the department’s contractor for an item or service solely on the basis that such item or service did not receive prior authorization under the third-party payer’s rules.(2) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the department shall make rules that:(2)(a) construe and implement Subsection (1)(e); and(2)(b) encourage health care providers to seek prior authorization when necessary from a health insurance entity that is the primary payer before seeking third-party liability through Medicaid.