2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 614.5 - Uniform claims processing -- Electronic exchange of health information.

Effective 5/3/2023
31A-22-614.5.
Uniform claims processing -- Electronic exchange of health information.
(1)
(a) Except as provided in Subsection (1)(c), an insurer offering health insurance shall use a uniform claim form and uniform billing and claim codes.
(b) Beginning January 1, 2011, all health benefit plans, and dental and vision plans, shall provide for the electronic exchange of uniform:
(i) eligibility and coverage information; and
(ii) coordination of benefits information.
(c) For purposes of Subsection (1)(a), "health insurance" does not include a policy or certificate that provides benefits solely for:
(i) income replacement; or
(ii) long-term care.
(2)
(a) The uniform electronic standards and information required in Subsection (1) shall be adopted and approved by the commissioner in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act.
(b) When adopting rules under this section the commissioner:
(i) shall:
(A) consult with national and state organizations involved with the standardized exchange of health data, and the electronic exchange of health data, to develop the standards for the use and electronic exchange of uniform:
(I) claim forms;
(II) billing and claim codes;
(III) insurance eligibility and coverage information; and
(IV) coordination of benefits information; and
(B) meet federal mandatory minimum standards following the adoption of national requirements for transaction and data elements in the federal Health Insurance Portability and Accountability Act;
(ii) may not require an insurer or administrator to use a specific software product or vendor; and
(iii) may require an insurer who participates in the all payer database created under Section 26B-8-504 to allow data regarding demographic and insurance coverage information to be electronically shared with the state's designated secure health information master person index to be used:
(A) in compliance with data security standards established by:
(I) the federal Health Insurance Portability and Accountability Act; and
(II) the electronic commerce agreements established in a business associate agreement; and
(B) for the purpose of coordination of health benefit plans.
(3)
(a) The commissioner shall coordinate the administrative rules adopted under the provisions of this section with the administrative rules adopted by the Department of Health and Human Services for the implementation of the standards for the electronic exchange of clinical health information under Section 26B-8-411. The department shall establish procedures for developing the rules adopted under this section, which ensure that the Department of Health and Human Services is given the opportunity to comment on proposed rules.
(b)
(i) The commissioner may provide information to health care providers regarding resources available to a health care provider to verify whether a health care provider's practice management software system meets the uniform electronic standards for data exchange required by this section.
(ii) The commissioner may provide the information described in Subsection (3)(b)(i) by partnering with:
(A) a not-for-profit, broad based coalition of state health care insurers and health care providers who are involved in the electronic exchange of the data required by this section; or
(B) some other person that the commissioner determines is appropriate to provide the information described in Subsection (3)(b)(i).
(c) The commissioner shall regulate any fees charged by insurers to the providers for:
(i) uniform claim forms;
(ii) electronic billing; or
(iii) the electronic exchange of clinical health information permitted by Section 26B-8-411.
(4) This section does not require a person to provide information concerning an employer self-insured employee welfare benefit plan as defined in 29 U.S.C. Sec. 1002(1).
Amended by Chapter 328, 2023 General Session