02-12 16:19 H.B. 495
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Health Care Amendments
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: James A. Dunnigan
Senate Sponsor:
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LONG TITLE
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General Description:
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This bill amends provisions related to health care practices.
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Highlighted Provisions:
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This bill:
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▸ amends provisions regarding the use of credit card payments to health care providers;
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▸ amends provisions related to dental claims practices; and
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▸ allows dentists to dispense medications under certain circumstances.
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Money Appropriated in this Bill:
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None
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Other Special Clauses:
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None
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Utah Code Sections Affected:
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AMENDS:
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31A-26-301.6, as last amended by Laws of Utah 2024, Chapter 120
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31A-26-301.7, as enacted by Laws of Utah 2021, Chapter 288
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58-88-201, as last amended by Laws of Utah 2023, Chapter 329
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58-88-202, as last amended by Laws of Utah 2024, Chapter 210
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Be it enacted by the Legislature of the state of Utah:
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Section 1. Section 31A-26-301.6 is amended to read:
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31A-26-301.6 . Health care claims practices.
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(1) As used in this section:
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(a) "Health care provider" means a person licensed to provide health care under:
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(i) Title 26B, Chapter 2, Part 2, Health Care Facility Licensing and Inspection; or
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(ii) Title 58, Occupations and Professions.
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(b) "Insurer" means an admitted or authorized insurer, as defined in Section 31A-1-301,
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and includes:
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(i) a health maintenance organization; and
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(ii) a third party administrator that is subject to this title, provided that nothing in this
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section may be construed as requiring a third party administrator to use its own
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funds to pay claims that have not been funded by the entity for which the third
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party administrator is paying claims.
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(c) "Provider" means a health care provider to whom an insurer is obligated to pay
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directly in connection with a claim by virtue of:
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(i) an agreement between the insurer and the provider;
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(ii) an accident and health insurance policy or contract of the insurer; or
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(iii) state or federal law.
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(2) An insurer shall timely pay every valid insurance claim submitted by a provider in
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accordance with this section.
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(3)(a) Except as provided in Subsection (4), within 30 days of the day on which the
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insurer receives a written claim, an insurer shall:
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(i) pay the claim; or
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(ii) deny the claim and provide a written explanation for the denial.
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(b)(i) Subject to Subsection (3)(b)(ii), the time period described in Subsection (3)(a)
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may be extended by 15 days if the insurer:
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(A) determines that the extension is necessary due to matters beyond the control
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of the insurer; and
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(B) before the end of the 30-day period described in Subsection (3)(a), notifies the
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provider and insured in writing of:
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(I) the circumstances requiring the extension of time; and
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(II) the date by which the insurer expects to pay the claim or deny the claim
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with a written explanation for the denial.
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(ii) If an extension is necessary due to a failure of the provider or insured to submit
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the information necessary to decide the claim:
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(A) the notice of extension required by this Subsection (3)(b) shall specifically
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describe the required information; and
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(B) the insurer shall give the provider or insured at least 45 days from the day on
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which the provider or insured receives the notice before the insurer denies the
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claim for failure to provide the information requested in Subsection
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(3)(b)(ii)(A).
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(4)(a) In the case of a claim for income replacement benefits, within 45 days of the day
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on which the insurer receives a written claim, an insurer shall:
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(i) pay the claim; or
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(ii) deny the claim and provide a written explanation of the denial.
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(b) Subject to Subsections (4)(d) and (e), the time period described in Subsection (4)(a)
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may be extended for 30 days if the insurer:
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(i) determines that the extension is necessary due to matters beyond the control of the
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insurer; and
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(ii) before the expiration of the 45-day period described in Subsection (4)(a), notifies
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the insured of:
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(A) the circumstances requiring the extension of time; and
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(B) the date by which the insurer expects to pay the claim or deny the claim with a
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written explanation for the denial.
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(c) Subject to Subsections (4)(d) and (e), the time period for complying with Subsection
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(4)(a) may be extended for up to an additional 30 days from the day on which the
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30-day extension period provided in Subsection (4)(b) ends if before the day on
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which the 30-day extension period ends, the insurer:
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(i) determines that due to matters beyond the control of the insurer a decision cannot
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be rendered within the 30-day extension period; and
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(ii) notifies the insured of:
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(A) the circumstances requiring the extension; and
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(B) the date as of which the insurer expects to pay the claim or deny the claim
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with a written explanation for the denial.
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(d) A notice of extension under this Subsection (4) shall specifically explain:
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(i) the standards on which entitlement to a benefit is based; and
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(ii) the unresolved issues that prevent a decision on the claim.
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(e) If an extension allowed by Subsection (4)(b) or (c) is necessary due to a failure of the
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insured to submit the information necessary to decide the claim:
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(i) the notice of extension required by Subsection (4)(b) or (c) shall specifically
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describe the necessary information; and
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(ii) the insurer shall give the insured at least 45 days from the day on which the
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insured receives the notice before the insurer denies the claim for failure to
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provide the information requested in Subsection (4)(b) or (c).
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(5) If a period of time is extended as permitted under Subsection (3)(b), (4)(b), or (4)(c),
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due to an insured or provider failing to submit information necessary to decide a claim,
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the period for making the benefit determination shall be tolled from the date on which
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the notification of the extension is sent to the insured or provider until the date on which
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the insured or provider responds to the request for additional information.
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(6) An insurer shall pay all sums to the provider or insured that the insurer is obligated to
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pay on the claim, and provide a written explanation of the insurer's decision regarding
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any part of the claim that is denied within 20 days of receiving the information requested
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under Subsection (3)(b), (4)(b), or (4)(c).
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(7)(a) Whenever an insurer makes a payment to a provider on any part of a claim under
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this section, the insurer shall also send to the insured an explanation of benefits paid.
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(b) Whenever an insurer denies any part of a claim under this section, the insurer shall
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also send to the insured:
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(i) a written explanation of the part of the claim that was denied; and
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(ii) notice of the adverse benefit determination review process established under
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Section 31A-22-629.
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(c) This Subsection (7) does not apply to a person receiving benefits under the state
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Medicaid program as defined in Section 26B-3-101, unless required by the
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Department of Health and Human Services or federal law.
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(8)(a) A late fee shall be imposed on:
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(i) an insurer that fails to timely pay a claim in accordance with this section; and
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(ii) a provider that fails to timely provide information on a claim in accordance with
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this section.
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(b) The late fee described in Subsection (8)(a) shall be determined by multiplying
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together:
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(i) the total amount of the claim the insurer is obliged to pay;
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(ii) the total number of days the response or the payment is late; and
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(iii) 0.033% daily interest rate.
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(c) Any late fee paid or collected under this Subsection (8) shall be separately identified
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on the documentation used by the insurer to pay the claim.
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(d) For purposes of this Subsection (8), "late fee" does not include an amount that is less
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than $1.
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(9) Each insurer shall establish a review process to resolve claims-related disputes between
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the insurer and providers.
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(10) An insurer or person representing an insurer may not engage in any unfair claim
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settlement practice with respect to a provider. Unfair claim settlement practices include:
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(a) knowingly misrepresenting a material fact or the contents of an insurance policy in
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connection with a claim;
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(b) failing to acknowledge and substantively respond within 15 days to any written
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communication from a provider relating to a pending claim;
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(c) denying or threatening to deny the payment of a claim for any reason that is not
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clearly described in the insured's policy;
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(d) failing to maintain a payment process sufficient to comply with this section;
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(e) failing to maintain claims documentation sufficient to demonstrate compliance with
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this section;
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(f) failing, upon request, to give to the provider written information regarding the
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specific rate and terms under which the provider will be paid for health care services;
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(g) failing to timely pay a valid claim in accordance with this section as a means of
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influencing, intimidating, retaliating, or gaining an advantage over the provider with
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respect to an unrelated claim, an undisputed part of a pending claim, or some other
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aspect of the contractual relationship;
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(h) failing to pay the sum when required and as required under Subsection (8) when a
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violation has occurred;
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(i) threatening to retaliate or actual retaliation against a provider for the provider
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applying this section;
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(j) any material violation of this section; and
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(k) any other unfair claim settlement practice established in rule or law.
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(11)(a) The provisions of this section shall apply to each contract between an insurer and
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a provider for the duration of the contract.
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(b) Notwithstanding Subsection (11)(a), this section may not be the basis for a bad faith
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insurance claim.
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(c) Nothing in Subsection (11)(a) may be construed as limiting the ability of an insurer
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and a provider from including provisions in their contract that are more stringent than
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the provisions of this section.
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(12)(a) Pursuant to Chapter 2, Part 2, Duties and Powers of Commissioner, the
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commissioner may conduct examinations to determine an insurer's level of
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compliance with this section and impose sanctions for each violation.
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(b) The commissioner may adopt rules only as necessary to implement this section.
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(c) The commissioner may establish rules to facilitate the exchange of electronic
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confirmations when claims-related information has been received.
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(d) Notwithstanding Subsection (12)(b), the commissioner may not adopt rules
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regarding the review process required by Subsection (9).
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(13) Nothing in this section may be construed as limiting the collection rights of a provider
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under Section 31A-26-301.5.
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(14) Nothing in this section may be construed as limiting the ability of an insurer to:
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(a) recover any amount improperly paid to a provider or an insured:
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(i) in accordance with Section 31A-31-103 or any other provision of state or federal
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law;
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(ii) within 24 months of the amount improperly paid for a coordination of benefits
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error;
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(iii) within 12 months of the amount improperly paid for any other reason not
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identified in Subsection (14)(a)(i) or (ii); or
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(iv) within 36 months of the amount improperly paid when the improper payment
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was due to a recovery by Medicaid, Medicare, the Children's Health Insurance
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Program, or any other state or federal health care program;
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(b) take any action against a provider that is permitted under the terms of the provider
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contract and not prohibited by this section;
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(c) report the provider to a state or federal agency with regulatory authority over the
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provider for unprofessional, unlawful, or fraudulent conduct; or
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(d) enter into a mutual agreement with a provider to resolve alleged violations of this
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section through mediation or binding arbitration.
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(15) A provider may only seek recovery from the insurer for an amount improperly paid by
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the insurer within the same time frames as Subsections (14)(a) and (b).
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(16)(a) An insurer may offer the remittance of payment through a credit card or other
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similar arrangement.
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(b)(i) A provider may elect not to receive remittance through a credit card or other
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similar arrangement.
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(ii) An insurer:
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(A) shall permit a provider's election described in Subsection (16)(b)(i) to apply to
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the provider's entire practice; [and]
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(B) may not require a provider's election described in Subsection (16)(b)(i) to be
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made on a patient-by-patient basis[.] ; and
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(C) shall allow a provider to opt out of all credit card or other similar
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arrangements for every plan offered by the insurer through a single opt out
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process.
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(iii) If a provider elects not to receive remittance through a credit card or other
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similar arrangement, that decision remains in effect until:
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(A) the provider affirmatively elects to receive remittance through credit card or
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similar arrangement; or
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(B) a new contract is issued.
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(c) An insurer may not require a provider or insured to accept remittance through a
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credit card or other similar arrangement.
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(d) An insurer shall accept a tangible check as a form of acceptable payment.
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Section 2. Section 31A-26-301.7 is amended to read:
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31A-26-301.7 . Dental claim transparency and practices.
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(1) As used in this section:
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(a) "Bundling" means the practice of combining distinct dental procedures into one
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procedure for billing purposes.
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(b) "Dental plan" means the same as that term is defined in Section 31A-22-646.
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(c) "Downcoding" means the adjustment of a claim submitted to a dental plan to a less
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complex or lower cost procedure code.
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(d) "Covered services" means the same as that term is defined in Section 31A-22-646.
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(e) "Material change" means a change to:
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(i) a dental plan's rules, guidelines, policies, or procedures concerning payment for
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dental services;
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(ii) the general policies of the dental plan that affect a reimbursement paid to
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providers; or
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(iii) the manner by which a dental plan adjudicates and pays a claim for services.
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(2) An insurer that contracts or renews a contract with a dental provider shall:
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(a) make a copy of the insurer's current dental plan policies available online; and
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(b) if requested by a provider, send a copy of the policies to the provider through mail or
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electronic mail.
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(3) Dental policies described in Subsection (2) shall include:
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(a) a summary of all material changes made to a dental plan since the policies were last
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updated;
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(b) the downcoding and bundling policies that the insurer reasonably expects to be
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applied to the dental provider or provider's services as a matter of policy; and
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(c) a description of the dental plan's utilization review procedures, including:
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(i) a procedure for an enrollee of the dental plan to obtain review of an adverse
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determination in accordance with Section 31A-22-629; and
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(ii) a statement of a provider's rights and responsibilities regarding the procedures
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described in Subsection (3)(c)(i).
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(4) An insurer may not maintain a dental plan that:
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(a) based on the provider's contracted fee for covered services, uses downcoding in a
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manner that prevents a dental provider from collecting the fee for the actual service
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performed from either the plan or the patient; [or]
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(b) uses bundling in a manner where a procedure code is labeled as nonbillable to the
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patient unless, under generally accepted practice standards, the procedure code is for
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a procedure that may be provided in conjunction with another procedure[.] ;
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(c) does not allow a dental provider to bill the patient for a service when the insurer
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denies the claim for the service, unless under generally accepted practice standards,
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the service performed should not be billed; or
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(d) automatically recoups an overpayment unless:
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(i) the recoupment occurs more than 60 days from the day the insurer sends a notice
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of the overpayment; or
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(ii) the dental provider affirmatively elects to have recoupment occur earlier than 60
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days from the day the insurer sends a notice of the overpayment.
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(5)(a) An insurer shall ensure that an explanation of benefits for a dental plan includes
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the reason for any downcoding or bundling result.
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(b) A dental provider who receives an overpayment from a dental plan shall return the
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amount of the overpayment through check or other means to the dental plan within
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60 days from the day the insurer sends a notice of the overpayment.
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(c) A dental provider shall make reasonable efforts to inform patients of services that
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may not be covered by the patient's dental plan if the dental provider will perform a
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service that may not be covered.
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Section 3. Section 58-88-201 is amended to read:
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58-88-201 . Definitions.
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As used in this part:
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(1)(a) "Dispense" means the delivery by a prescriber of a prescription drug or device to a
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patient, including the packaging, labeling, and security necessary to prepare and
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safeguard the drug or device for supplying to a patient.
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(b) "Dispense" does not include:
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(i) prescribing or administering a drug or device; or
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(ii) delivering to a patient a sample packaged for individual use by a licensed
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manufacturer or re-packager of a drug or device.
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(2) "Dispensing practitioner" means an individual who:
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(a) is currently licensed as:
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(i) a physician and surgeon under Chapter 67, Utah Medical Practice Act;
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(ii) an osteopathic physician and surgeon under Chapter 68, Utah Osteopathic
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Medical Practice Act;
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(iii) an advanced practice registered nurse under Subsection 58-31b-301(2)(d); [or]
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(iv) a physician assistant under Chapter 70a, Utah Physician Assistant Act; or
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(v) a dentist under Chapter 69, Dentist and Dental Hygienist Practice Act;
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(b) is authorized by state law to prescribe and administer drugs in the course of
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professional practice; and
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(c) practices at a licensed dispensing practice.
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(3) "Drug" means the same as that term is defined in Section 58-17b-102.
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(4) "Health care practice" means:
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(a) a health care facility as defined in Section 26B-2-201; or
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(b) the offices of one or more private prescribers, whether for individual or group
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practice.
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(5) "Licensed dispensing practice" means a health care practice that is licensed as a
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dispensing practice under Section 58-88-202.
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Section 4. Section 58-88-202 is amended to read:
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58-88-202 . Dispensing practice -- Drugs that may be dispensed -- Limitations
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and exceptions.
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(1) Notwithstanding Section 58-17b-302, a dispensing practitioner may dispense a drug at a
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licensed dispensing practice if the drug is:
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(a) packaged in a fixed quantity per package by:
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(i) the drug manufacturer;
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(ii) a pharmaceutical wholesaler or distributor; or
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(iii) a pharmacy licensed under Chapter 17b, Pharmacy Practice Act;
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(b) dispensed:
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(i) at a licensed dispensing practice at which the dispensing practitioner regularly
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practices; and
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(ii) under a prescription issued by the dispensing practitioner to the dispensing
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practitioner's patient;
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(c) except as provided in Subsection (6), for a condition that is not expected to last
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longer than 30 days; and
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(d) for a condition for which the patient has been evaluated by the dispensing
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practitioner on the same day on which the dispensing practitioner dispenses the drug.
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(2) A dispensing practitioner may not dispense:
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(a) a controlled substance as defined in Section 58-37-2;
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(b) a drug or class of drugs that is designated by the division under Subsection 58-88-205
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(2); or
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[(c) gabapentin; or]
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[(d)] (c) a supply of a drug under this part that exceeds a 30-day supply.
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(3) A dispensing practitioner may not make a claim against workers' compensation or
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automobile insurance for a drug dispensed under this part for outpatient use unless the
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dispensing practitioner is contracted with a pharmacy network established by the claim
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payor.
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(4) When a dispensing practitioner dispenses a drug to the patient under this part, a
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dispensing practitioner shall:
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(a) disclose to the patient verbally and in writing that the patient is not required to fill the
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prescription through the licensed dispensing practice and that the patient has a right
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to fill the prescription through a pharmacy; and
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(b) if the patient will be responsible to pay cash for the drug, disclose:
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(i) that the patient will be responsible to pay cash for the drug; and
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(ii) the amount that the patient will be charged by the licensed dispensing practice for
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the drug.
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(5) This part does not:
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(a) require a dispensing practitioner to dispense a drug under this part;
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(b) limit a health care prescriber from dispensing under Chapter 17b, Part 8, Dispensing
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Medical Practitioner and Dispensing Medical Practitioner Clinic Pharmacy; or
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(c) apply to a physician who dispenses:
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(i) a drug sample, as defined in Section 58-17b-102, to a patient in accordance with
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Section 58-1-501.3 or Section 58-17b-610; or
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(ii) a drug in an emergency situation as defined by the division in rule under Chapter
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17b, Pharmacy Practice Act.
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(6) A dispensing practitioner that is a dentist may dispense prescription fluoride medication
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regardless of whether the condition the fluoride is treating will last longer than 30 days.
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Section 5. Effective Date.
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This bill takes effect on May 7, 2025.
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