Utah Admin. Code R590-131-8 - Miscellaneous Provisions
(1) Reasonable Cash
Value of Services.
(a) A secondary plan that
provides a benefit in the form of a service may recover the reasonable cash
value of providing the service from the primary plan, if the service is covered
by the primary plan and has not been paid or provided by the primary
plan.
(b) Nothing in this
Subsection may be interpreted to require a plan to reimburse an enrollee the
cash value of a service provided by a plan that provides a benefit in the form
of a service.
(2) Excess
and Other Provisions.
(a) Except as provided
in Subsection (2)(b), a conforming plan may not contain a provision that the
plan benefits are excess or always secondary to any other plan or
policy.
(b) A b lanket
accident-only plan may contain a provision that its benefits are excess or
always secondary to any other plan.
(3) Non-conforming Plan.
(a) A conforming plan may coordinate benefits
with a non-conforming plan.
(i) If the
conforming plan is the primary plan, it shall pay or provide its benefits as
the primary plan;
(ii) If the
conforming plan is the secondary plan, it shall pay or provide its benefits as
the secondary plan, and the payment shall be the limit of the conforming plan's
liability.
(iii) If the
non-conforming plan does not provide the information needed by the conforming
plan to determine its benefits within a reasonable time after it is requested
to do so, the conforming plan shall assume that the benefits of the
non-conforming plan are identical to its own and shall pay its benefits
accordingly.
(iv) If the conforming
plan receives information as to the actual benefits of the non-conforming plan,
it may adjust any payments in compliance with Subsection
31A-26-301.6(14)(a)(ii).
(b)
(i) If a non-conforming plan reduces its
benefits so that the enrollee receives less in benefits than the enrollee would
have received had the conforming plan paid or provided its benefits as the
secondary plan, and the non-conforming plan paid or provided its benefits as
the primary plan, then the conforming plan shall advance to the enrollee, or on
behalf of the enrollee, an amount equal to the difference.
(ii) In no event shall the conforming plan
advance more than the conforming plan would have paid had it been the primary
plan, less any amount it had previously paid.
(iii) In consideration of an advance, the
conforming plan shall be subrogated to all rights of the covered person against
the non-conforming plan in the absence of subrogation.
(iv) An advance by the conforming plan shall
be without prejudice to any claim it may have against a non-conforming plan in
the absence of subrogation.
(4) Subrogation.
COB differs from subrogation. Provisions for either COB or subrogation may be included in a contract without compelling the inclusion or exclusion of the other.
(5)
Right To Receive and Release Needed Information.
(a) An insurer may obtain or give needed
information to another person without obtaining consent from an enrollee.
(b) To facilitate cooperation with
insurers, guidelines for medical privacy issues are provided under Rule
R590-206, Privacy of Consumer Financial and Health Information Rule, and
Gramm-Leach-Bliley Act of 1999,
15 U.S.C.
6801 et. seq.
(c) Each enrollee claiming benefits under a
plan shall give the insurer any information necessary to pay the
claim.
(6) Right of
Recovery.
(a) If an insurer is paid more than
required under this rule, subject to Section 31A-26-301.6, the insurer may
recover the overpayment from one or more of the following:
(i) the enrollee;
(ii) the provider;
(iii) an insurer; or
(iv) another organization.
(b) The insurer is responsible for
adjustments between insurers and providers.
(7) Notice to Enrollee. The explanation of
benefits provided to an enrollee shall include, "If you are covered by more
than one health benefit plan, you should file all your claims with each
plan."
(8) If covered benefits are
due to a loss under Section
31A-22-306,
an accident and health insurer may exclude benefits covered by personal injury
protection described in Subsection
31A-22-307(1)(a),
up to :
(a) the personal injury protection
benefit provided by motor vehicle insurance; or
(b) if motor vehicle insurance is not in
effect, the minimum amount provided in Subsection
31A-22-307(1)(a).
(9) Facility of Payment.
(a) If a plan pays an amount that should have
been paid under an insurer's plan, the insurer may pay that amount to the other
plan.
(b) The amount the insurer
pays to the other plan is treated as a benefit paid under the plan and the
insurer will not have to pay that amount again.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.