26B-3-1011. Notice of claim by recipient — Department response — Conditions for proceeding — Collection agreements.
(1)
Terms Used In Utah Code 26B-3-1011
Claim: means :
(a)
a request or demand for payment; or
(b)
a cause of action for money or damages arising under any law. See Utah Code 26B-3-1001
Lien: A claim against real or personal property in satisfaction of a debt.
Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
Medical assistance: means :
(a)
all funds expended for the benefit of a recipient under this chapter or Titles XVIII and XIX, federal Social Security Act; and
(b)
any other services provided for the benefit of a recipient by a prepaid health care delivery system under contract with the department. See Utah Code 26B-3-1001
Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
Office of Recovery Services: means the Office of Recovery Services within the department. See Utah Code 26B-3-1001
Recipient: means :
(a)
an individual who has applied for or received medical assistance from the state;
(b)
the guardian, conservator, or other personal representative of an individual under Subsection (11)(a) if the individual is a minor or an incapacitated person; or
(c)
the estate and survivors of an individual under Subsection (11)(a), if the individual is deceased. See Utah Code 26B-3-1001
State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
Third party: includes :
(a)
an individual, institution, corporation, public or private agency, trust, estate, insurance carrier, employee welfare benefit plan, health maintenance organization, health service organization, preferred provider organization, governmental program such as Medicare, CHAMPUS, and workers' compensation, which may be obligated to pay all or part of the medical costs of injury, disease, or disability of a recipient, unless any of these are excluded by department rule; and
(b)
a spouse or a parent who:
(i)
may be obligated to pay all or part of the medical costs of a recipient under law or by court or administrative order; or
(ii)
has been ordered to maintain health, dental, or accident and health insurance to cover medical expenses of a spouse or dependent child by court or administrative order. See Utah Code 26B-3-1001
A recipient may not file a claim, commence an action, or settle, compromise, release, or waive a claim against a third party for recovery of medical costs for an injury, disease, or disability for which the department has provided or has become obligated to provide medical assistance, without the department’s written consent as provided in Subsection (2)(b) or (4).
(b)
For purposes of Subsection (1)(a), consent may be obtained if:
(i)
a recipient who files a claim, or commences an action against a third party notifies the department in accordance with Subsection (1)(d) within 10 days of the recipient making the claim or commencing an action; or
(ii)
an attorney, who has been retained by the recipient to file a claim, or commence an action against a third party, notifies the department in accordance with Subsection (1)(d) of the recipient’s claim:
(A)
within 30 days after being retained by the recipient for that purpose; or
(B)
within 30 days from the date the attorney either knew or should have known that the recipient received medical assistance from the department.
(c)
Service of the notice of claim to the department shall be made by certified mail, personal service, or by e-mail in accordance with Rule 5 of the Utah Rules of Civil Procedure, to the director of the Office of Recovery Services.
(d)
The notice of claim shall include the following information:
(i)
the name of the recipient;
(ii)
the recipient’s Social Security number;
(iii)
the recipient’s date of birth;
(iv)
the name of the recipient’s attorney if applicable;
(v)
the name or names of individuals or entities against whom the recipient is making the claim, if known;
(vi)
the name of the third party’s insurance carrier, if known;
(vii)
the date of the incident giving rise to the claim; and
(viii)
a short statement identifying the nature of the recipient’s claim.
(2)
(a)
Within 30 days of receipt of the notice of the claim required in Subsection (1), the department shall acknowledge receipt of the notice of the claim to the recipient or the recipient’s attorney and shall notify the recipient or the recipient’s attorney in writing of the following:
(i)
if the department has a claim or lien pursuant to Section 26B-3-1009 or has become obligated to provide medical assistance; and
(ii)
whether the department is denying or granting written consent in accordance with Subsection (1)(a).
(b)
The department shall provide the recipient’s attorney the opportunity to enter into a collection agreement with the department, with the recipient’s consent, unless:
(i)
the department, prior to the receipt of the notice of the recipient’s claim pursuant to Subsection (1), filed a written claim with the third party, the third party agreed to make payment to the department before the date the department received notice of the recipient’s claim, and the agreement is documented in the department’s record; or
(ii)
there has been a failure by the recipient’s attorney to comply with any provision of this section by:
(A)
failing to comply with the notice provisions of this section;
(B)
failing or refusing to enter into a collection agreement;
(C)
failing to comply with the terms of a collection agreement with the department; or
(D)
failing to disburse funds owed to the state in accordance with this section.
(c)
(i)
The collection agreement shall be:
(A)
consistent with this section and the attorney’s obligation to represent the recipient and represent the state’s claim; and
(B)
state the terms under which the interests of the department may be represented in an action commenced by the recipient.
(ii)
If the recipient’s attorney enters into a written collection agreement with the department, or includes the department’s claim in the recipient’s claim or action pursuant to Subsection (4), the department shall pay attorney fees at the rate of 33.3% of the department’s total recovery and shall pay a proportionate share of the litigation expenses directly related to the action.
(d)
The department is not required to enter into a collection agreement with the recipient’s attorney for collection of personal injury protection under Subsection 31A-22-302(2).
(3)
(a)
If the department receives notice pursuant to Subsection (1), and notifies the recipient and the recipient’s attorney that the department will not enter into a collection agreement with the recipient’s attorney, the recipient may proceed with the recipient’s claim or action against the third party if the recipient excludes from the claim:
(i)
any medical expenses paid by the department; or
(ii)
any medical costs for which the department is obligated to provide medical assistance.
(b)
When a recipient proceeds with a claim under Subsection (3)(a), the recipient shall provide written notice to the third party of the exclusion of the department’s claim for expenses under Subsection (3)(a)(i) or (ii).
(4)
If the department receives notice pursuant to Subsection (1), and does not respond within 30 days to the recipient or the recipient’s attorney, the recipient or the recipient’s attorney:
(a)
may proceed with the recipient’s claim or action against the third party;
(b)
may include the state’s claim in the recipient’s claim or action; and
(c)
may not negotiate, compromise, settle, or waive the department’s claim without the department’s consent.
Renumbered and Amended by Chapter 306, 2023 General Session
