Utah Code 31A-26-301.5. Health care claims practices
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Terms Used In Utah Code 31A-26-301.5
- Form: means one of the following prepared for general use:(74)(a)(i) a policy;(74)(a)(ii) a certificate;(74)(a)(iii) an application;(74)(a)(iv) an outline of coverage; or(74)(a)(v) an endorsement. 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- health insurance: means insurance providing:
(84)(a)(i) a health care benefit; or(84)(a)(ii) payment of an incurred health care expense. See Utah Code 31A-1-301- Individual: means a natural person. 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- Participating: means a plan of insurance under which the insured is entitled to receive a dividend representing a share of the surplus of the insurer. See Utah Code 31A-1-301
- Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
- Rate: means :
(163)(a)(i) the cost of a given unit of insurance; or(163)(a)(ii) for property or casualty insurance, that cost of insurance per exposure unit either expressed as:(163)(a)(ii)(A) a single number; or(163)(a)(ii)(B) a pure premium rate, adjusted before the application of individual risk variations based on loss or expense considerations to account for the treatment of:(163)(a)(ii)(B)(I) expenses;(163)(a)(ii)(B)(II) profit; and(163)(a)(ii)(B)(III) individual insurer variation in loss experience. See Utah Code 31A-1-301(1)(a) Except as provided in Section 31A-8-407, an insured retains ultimate responsibility for paying for health care services the insured receives.(1)(b) If a health care service is covered by one or more individual or group health insurance policies, all insurers covering the insured have the responsibility to pay valid health care claims in a timely manner according to the terms and limits specified in the policies.(2) A health care provider may:(2)(a) except as provided in Section 31A-22-610.1, bill and collect for any deductible, copayment, or uncovered service; and(2)(b) bill an insured for services covered by health insurance policies or otherwise notify the insured of the expenses covered by the policies.(3) Beginning October 31, 1992, all insurers covering the insured shall notify the insured of payment and the amount of payment made to the health care provider.(4) A health care provider shall return to an insured any amount the insured overpaid, including interest that begins accruing 90 days after the date of the overpayment, if:(4)(a) the insured has multiple insurers with whom the health care provider has contracts that cover the insured; and(4)(b) the health care provider becomes aware that the health care provider has received, for any reason, payment for a claim in an amount greater than the health care provider’s contracted rate allows.(5)(5)(a) The commissioner shall make rules consistent with this chapter governing disclosure to the insured of customary charges by health care providers on the explanation of benefits as part of the claims payment process.(5)(b) These rules shall be limited to the form and content of the disclosures on the explanation of benefits, and shall include:(5)(b)(i) a requirement that the method of determination of any specifically referenced customary charges and the range of the customary charges be disclosed; and(5)(b)(ii) a prohibition against an implication that the health care provider is charging excessively if the health care provider is:(5)(b)(ii)(A) a participating provider; and(5)(b)(ii)(B) prohibited from balance billing. - Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment: