2023 Utah Code › Title 31A - Insurance Code › Chapter 45 - Managed Care Organizations › Part 3 - Relationships with Providers › Section 303 - Network provider contract provisions.

Effective 5/14/2019
31A-45-303.
Network provider contract provisions.
(1) Managed care organizations may provide for enrollees to receive services or reimbursement in accordance with this section.
(2)
(a) Subject to restrictions under this section, a managed care organization may enter into contracts with health care providers under which the health care providers agree to be a network provider and supply services, at prices specified in the contracts, to enrollees.
(b) A network provider contract shall require the network provider to accept the specified payment in this Subsection (2) as payment in full, relinquishing the right to collect amounts other than copayments, coinsurance, and deductibles from the enrollee.
(c) The insurance contract may reward the enrollee for selection of network providers by:
(i) reducing premium rates;
(ii) reducing deductibles;
(iii) coinsurance;
(iv) other copayments; or
(v) any other reasonable manner.
(3)
(a) When reimbursing for services of health care providers that are not network providers, the managed care organization may:
(i) make direct payment to the enrollee; and
(ii) impose a deductible on coverage of health care providers not under contract.
(b)
(i) Subsections (3)(b)(iii) and (c) apply to a managed care organization licensed under:
(A)Chapter 5, Domestic Stock and Mutual Insurance Corporations;
(B)Chapter 7, Nonprofit Health Service Insurance Corporations; or
(C)Chapter 14, Foreign Insurers; and
(ii) Subsections (3)(b)(iii) and (c) and Subsection (6)(b) do not apply to a managed care organization licensed under Chapter 8, Health Maintenance Organizations and Limited Health Plans.
(iii) When selecting health care providers with whom to contract under Subsection (2), a managed care organization described in Subsection (3)(b)(i) may not unfairly discriminate between classes of health care providers, but may discriminate within a class of health care providers, subject to Subsection (6).
(c) For purposes of this section, unfair discrimination between classes of health care providers includes:
(i) refusal to contract with class members in reasonable proportion to the number of insureds covered by the insurer and the expected demand for services from class members; and
(ii) refusal to cover procedures for one class of providers that are:
(A) commonly used by members of the class of health care providers for the treatment of illnesses, injuries, or conditions;
(B) otherwise covered by the managed care organization; and
(C) within the scope of practice of the class of health care providers.
(4) Before the enrollee consents to the insurance contract, the managed care organization shall fully disclose to the enrollee that the managed care organization has entered into network provider contracts. The managed care organization shall provide sufficient detail on the network provider contracts to permit the enrollee to agree to the terms of the insurance contract. The managed care organization shall provide at least the following information:
(a) a list of the health care providers under contract, and if requested their business locations and specialties;
(b) a description of the insured benefits, including deductibles, coinsurance, or other copayments;
(c) a description of the quality assurance program required under Subsection (5); and
(d) a description of the adverse benefit determination procedures required under Section 31A-22-629.
(5)
(a) A managed care organization using network provider contracts shall maintain a quality assurance program for assuring that the care provided by the network providers meets prevailing standards in the state.
(b) The commissioner in consultation with the executive director of the Department of Health may designate qualified persons to perform an audit of the quality assurance program. The auditors shall have full access to all records of the managed care organization and the managed care organization's health care providers, including medical records of individual patients.
(c) The information contained in the medical records of individual patients shall remain confidential. All information, interviews, reports, statements, memoranda, or other data furnished for purposes of the audit and any findings or conclusions of the auditors are privileged. The information is not subject to discovery, use, or receipt in evidence in any legal proceeding except hearings before the commissioner concerning alleged violations of this section.
(6)
(a) A health care provider or managed care organization may not discriminate against a network provider for agreeing to a contract under Subsection (2).
(b)
(i) Subsections (6)(b) and (c) apply to a managed care organization that is described in Subsection (3)(b)(i) and do not apply to a managed care organization described in Subsection (3)(b)(ii).
(ii) A health care provider licensed to treat an illness or injury within the scope of the health care provider's practice, that is willing and able to meet the terms and conditions established by the managed care organization for designation as a network provider, shall be able to apply for and receive the designation as a network provider. Contract terms and conditions may include reasonable limitations on the number of designated network providers based upon substantial objective and economic grounds, or expected use of particular services based upon prior provider-patient profiles.
(c) Upon the written request of a provider excluded from a network provider contract, the commissioner may hold a hearing to determine if the managed care organization's exclusion of the provider is based on the criteria set forth in Subsection (6)(b).
(7) Nothing in this section is to be construed as to require a managed care organization to offer a certain benefit or service as part of a health benefit plan.
(8) Notwithstanding Subsection (2) or (6)(b), a managed care organization described in Subsection (3)(b)(i) or third party administrator is not required to, but may, enter into a contract with a licensed athletic trainer, licensed under Title 58, Chapter 40a, Athletic Trainer Licensing Act.
Amended by Chapter 193, 2019 General Session