USHAI 360P-1 Billing Insurance 

New 03/03 Revised 09/24/03

UCA 26-19-4.5; UCA 26-19-5; UCA 26-19-14


Statutory Authority


UCA 26-19-5 states:

(1) (a) When the department provides or becomes obligated to provide medical assistance to a recipient because of an injury, disease, or disability that a third party is obligated to pay for, the department may recover the medical assistance directly from that third party.”

UCA 26-19-4.5 states:

“(1) (a) To the extent that medical assistance is actually provided to a recipient, all benefits for medical services or payments from a third party otherwise payable to or on behalf of a recipient are assigned by operation of law to the department if the department provides, or becomes obligated to provide, medical assistance, regardless of who made application for the benefits on behalf of the recipient.
     (b) The assignment:
     (i) authorizes the department to submit its claim to the third party and authorizes payment of benefits directly to the department; and
     (ii) is effective for all medical assistance.”


Billing Procedures


The Office of Recovery Services (ORS) is the designated private insurance billing agent for the Utah State Hospital (USH).  If insurance coverage is verified and payments are expected, file a claim for services each month following the service month, for the entire cost of care at the USH.  Current billing practices require ORS to bill under an all-inclusive rate; thus, services are not broken down by specific medical service codes, and billings are sent for an entire month of service.  Use the UB92 (Y62A) billing statement form to bill an insurance company.  Prepare a separate UB92 form for each month the patient stays at the USH.


If the patient has a primary and a secondary insurance company, bill the primary insurance company first.  After the primary insurance company has responded to the UB92 billing statement, bill the secondary insurance company for the remaining balance due.  Include the Primary Carrier’s Explanation of Benefits (form EOB) when billing secondary insurance companies.


Denied Claims


UCA 26-19-14(1) states, “(1) A policy of accident or sickness insurance issued or renewed after May 12, 1981, may not contain any provision denying or reducing benefits because services are rendered to an insured or dependent who is eligible for or receiving medical assistance from the state.”

Monitor the insurance case for payments.  Contact the insurance company if no payment or denial is received by ORS within 60 days of the billing date. 

Upon referral from ORS, the USH may challenge denied claims on a case-by-case basis; utilize treatment notes, physician letters, or itemized charges.  When the insurance company continues to deny a valid claim that the USH and ORS worker have unsuccessfully challenged, the case may be referred to the Attorney General’s office after receiving authorization from the USH.


On valid denials of payment from insurance companies, close the insurance case (refer to USHAI 061 Case Closure for closure procedures).  Make appropriate case narrative documentation on the 690 screen why the insurance denial is appropriate and the case closure necessary.  E-mail a copy of the narrative to the USH.


Medicare Payments


The USH has retained the responsibility to collect Medicare payments in accordance with 26-19-5 and 26-19-4.5.  If Medicare is the primary insurance and another insurance company is the secondary insurance, bill the secondary insurance the remaining amount, shown on the 835 posting report as “co-insurance.”  The USH sends ORS the 835 posting report (Medicare EOB), which shows how much they have received in Medicare.  If billing secondary insurance after Medicare payments have been received, include a copy of the posting report with the UB92 billing statement (form Y62A).  ORS retains the responsibility for billing supplemental insurance carriers, since these companies are not automatically billed through Medicare.