Utah Admin. Code R612-300-7 - Billing and Payment
A. Billing
Limitations.
1. Except as otherwise provided
by a specific provision of the Workers' Compensation Act or these rules, an
injured worker may not be billed for the cost of medical care necessary to
treat his or her workplace injuries.
2. A health care provider may not submit a
bill for medical care of an injured worker to both the employer and the
insurance carrier.
B.
Discounting and down-coding.
1. Discounting or
reducing the fees established by these rules is permitted only pursuant to a
specific written contract between the medical provider and payor/guarantor, or
an agent of the payor/guarantor, through a bona fide provider network
arrangement, and is disclosed to the provider. A third party administrator or
claims processing agency may not apply a discount absent a specific written
contract with the provider.
2. A
payor may change the CPT code submitted by a health care provider under the
following circumstances:
a. The submitted code
is incorrect;
b. Another code more
closely identifies the medical care;
c. The medical provider has not submitted the
documentation necessary to support the code; or
d. The medical care is part of a larger
procedure and included in the fee for that procedure.
3. If a payor changes a code number, the
payor shall explain the reason for the change and provide the name and phone
number of the payor's claims processor to the medical provider in order to
allow further discussion.
C. Place of Treatment. A medical provider's
billing for a medical procedure must identify the setting where a procedure was
performed.
1. In an office or clinic: Fees
for procedures performed in an office or clinic are to be computed using the
Non-Facility Total RVU.
2. In a
facility setting: Fees for physician services for procedures performed in a
facility are to be computed using the "Facility Total RVU," as the facility
will be billing for the direct and indirect costs related to the
service.
D. Separate
Bills. Separate bills must be presented by each medical provider within one
year of the date of service on a HCFA 1500 billing form. All bills must contain
the federal ID number of the provider submitting the bill.
E. Hospital Fees.
1. Fees covering hospital care shall be
separate from those for professional services and shall not extend beyond the
actual necessary hospital care.
2.
All billings must be submitted on a UB92 form, properly itemized and coded, and
shall include all documentation, including discharge summary, necessary to
support the billing. No separate fee may be charged for billing or
documentation of hospital services.
3. Fees charged by health care providers for
services performed in a hospital are subject to the Commission's fee
rules.
F. Charges for
Supplies, Materials, or Drugs.
1. Ordinary
supplies, materials or drugs used in treatment shall not be charged separately
but shall be included in the amount allowed for the underlying medical
care.
2. Special or unusual
supplies, materials, or drugs not included as a normal and usual part of the
service or procedure may be billed at cost plus 15% restocking fees and any
taxes paid. Discounts shall not apply to supplies.
G. Miscellaneous.
1. A physician may bill the new patient E and
M code when seeing an established patient for a new work injury.
2. Payment for hospital care is limited to
the bed rate for semi-private room unless a private room is medically
necessary.
3. Non-facility RVS
total unit values apply, except that procedures provided in a facility setting
shall be reimbursed at the facility total unit value and the facility may bill
a separate facility charge.
4.
Items that are a portion of an overall procedure are NOT to be itemized or
billed separately.
5. Payors may
round charges to the nearest dollar. If this is done on some charges, it must
be done with all charges.
H. Prompt Payment and Interest.
1. All bills for medical care of injured
workers must be paid within 45 days of submission to the payor unless the bill
or some portion of the bill is in dispute. Any portion of the bill not in
dispute remains payable within 45 days of billing.
2. As required by Section
34A-2-420
of the Utah Workers' Compensation Act, any award for medical care made by the
Commission shall include interest at 8% per annum from the date of billing for
such medical care.
I.
Billing Disputes. Payors and health care providers shall use the following
procedures to resolve billing disputes.
1.
The provider shall submit a bill for services with supporting documentation to
the payor within one year of the date of service.
2. The payor shall evaluate the bill and pay
the appropriate fee as established by these rules.
3. If the provider believes the payor has
improperly computed the fee, the provider may submit a written request for
reevaluation to the payor. The request shall describe the specific areas of
disagreement and include all appropriate documentation. Any such request for
re-evaluation must be submitted to the payor within one year of the date of the
original payment.
4. Within 30 days
of receipt of the request for re-evaluation, the payor shall either pay the
additional fee due the provider or respond with a specific written explanation
of the basis for its denial of additional fees. The payor shall maintain proof
of transmittal of its response.
5.
A payor seeking reimbursement from a provider for overpayment of a bill shall,
within one year of the overpayment, submit to the provider a written request
for repayment that explains the basis for request. Within 90 days of receipt of
the request, the provider shall either make appropriate repayment or respond
with a specific written denial of the request.
6. If the provider and payor continue to
disagree regarding the proper fee, either party may request informal review of
the matter by the Division. Any party may also file a request for hearing on
the dispute with the Adjudication Division.
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.