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 contract between the medical provider and payor.

  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 30 days of treatment on a HCFA 1500 billing form. All bills must contain the federal ID number of the provider submitting the bill.

  E. Hospital Fees.

  1. The Labor Commission does not have authority to set fees for hospital care of injured workers. However, hospitals are subject to the Commission's reporting requirements, and fees charged by health care providers for services performed in a hospital are subject to the Commission's fee rules.

  2. Fees covering hospital care shall be separate from those for professional services and shall not extend beyond the actual necessary hospital care.

  3. 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.

  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.

  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.