31A-45-304. Objective criteria for adding or terminating network providers — Termination of contracts — Review process.
(1)
Terms Used In Utah Code 31A-45-304
Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
Application: means a document:
(a)
(i)
completed by an applicant to provide information about the risk to be insured; and
(ii)
that contains information that is used by the insurer to evaluate risk and decide whether to:
(A)
insure the risk under:
(I)
the coverage as originally offered; or
(II)
a modification of the coverage as originally offered; or
(B)
decline to insure the risk; or
(b)
used by the insurer to gather information from the applicant before issuance of an annuity contract. See Utah Code 31A-1-301
Contract: A legal written agreement that becomes binding when signed.
a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
(ii)
a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
(iii)
a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
Managed care organization: means :
(a)
a managed care organization as that term is defined in Section 31A-1-301; and
Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. See Utah Code 31A-1-301
Probation: A sentencing alternative to imprisonment in which the court releases convicted defendants under supervision as long as certain conditions are observed.
Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
(a)
A managed care organization shall establish criteria for adding health care providers to a new or existing network provider panel.
number of health care providers needed to adequately serve the managed care organization’s population; and
(iii)
any other factor that is reasonably related to promote or protect good patient care, address costs, take into account on-call and cross-coverage relationships between providers, or serve the lawful interests of the managed care organization.
(c)
A managed care organization shall make such criteria available to any provider upon request and shall file the same with the department.
(d)
Upon receipt of a provider application and upon receiving all necessary information, a managed care organization shall make a decision on a provider’s application for participation within 120 days.
(e)
If the provider applicant is rejected, the managed care organization shall inform the provider of the reason for the rejection relative to the criteria established in accordance with Subsection (1)(b).
(f)
A managed care organization may not reject a provider applicant based solely on:
(i)
the provider’s staff privileges at a general acute care hospital not under contract with the managed care organization; or
(ii)
the provider’s referral patterns for patients who are not covered by the managed care organization.
(g)
Criteria set out in Subsection (1)(b) may be modified or changed from time to time to meet the business needs of the market in which the managed care organization operates and, if modified, will be filed with the department as provided in Subsection (1)(c).
(h)
With the exception of Subsection (1)(f), this section does not create any new or additional private right of action for redress.
(2)
(a)
For the first two years, a managed care organization may terminate its contract with a provider with or without cause upon giving the requisite amount of notice provided in the agreement, but in no case shall it be less than 60 days.
(b)
An agreement may be terminated for cause as provided in the contract established between the managed care organization and the provider. Such contract shall contain sufficiently certain criteria so that the provider can be reasonably informed of the grounds for termination for cause.
(c)
Before termination for cause, the managed care organization:
(i)
shall inform the provider of the intent to terminate and the grounds for doing so;
(ii)
shall at the request of the provider, meet with the provider to discuss the reasons for termination;
(iii)
if the managed care organization has a reasonable basis to believe that the provider may correct the conduct giving rise to the notice of termination, may, at its discretion, place the provider on probation with corrective action requirements, restrictions, or both, as necessary to protect patient care; and
(iv)
if the managed care organization has a reasonable basis to believe that the provider has engaged in fraudulent conduct or poses a significant risk to patient care or safety, may immediately suspend the provider from further performance under the contract, provided that the remaining provisions of this Subsection (2) are followed in a timely manner before termination may become final.
(d)
Each managed care organization shall establish an internal appeal process for actions that may result in terminated participation with cause and make known to the provider the procedure for appealing such termination.
(i)
Providers dissatisfied with the results of the appeal process may, if both parties agree, submit the matters in dispute to mediation.
(ii)
If the matters in dispute are not mediated, or should mediation be unsuccessful, the dispute shall be subject to binding arbitration by an arbitrator jointly selected by the parties, the cost of which shall be jointly shared. Each party shall bear its own additional expenses.
(e)
A termination under Subsection (2)(a) or (b) may not be based on:
(i)
the provider’s staff privileges at a general acute care hospital not under contract with the managed care organization; or
(ii)
the provider’s referral patterns for patients who are not covered by the managed care organization.
(3)
Notwithstanding any other section of this title, a managed care organization may not take adverse action against or reduce reimbursement to a network provider who is not under a capitated reimbursement arrangement because of the decision of an enrollee to access health care services from a non-network provider in a manner permitted by the enrollee’s health insurance plan, regardless of how the plan is designated.
Renumbered and Amended by Chapter 292, 2017 General Session
