USHAI 360P Billing Definitions, Forms, and General Information
New 03/03 Revised
UCA 26-19-4.5; UCA 26-19-5; UCA 62A-15-607; UCA 62A-15-617
UCA 62A-15-607 and 62A-15-617 authorize the Division of Mental Health to assess and require payments from the applicant, patient, spouse, parents, child, children, or guardian of the patient whether the patient is voluntarily or involuntarily placed at the state hospital. Refer to USHAI 360a Billing Insurance for further information.
UCA 26-19-4.5 and 26-19-5 authorize the Department of Health to file claims directly against third parties to recoup its expenses when it has provided medical assistance to a patient. Third parties may include individuals, trusts, estates, and insurance carriers. Refer to USHAI 360b Adult Patient and Patient’s Spouse Assessment – Procedures for further information.
ORS has a contractual relationship with the Utah State Hospital (USH) in implementing collection powers on behalf of the Hospital. The Office of Recovery Services (ORS) is given specific authority under this relationship to determine and collect payments from all potential private parties and insurance carriers. However, the hospital has retained the responsibility to collect Medicaid, Medicare, and Social Security benefits.
Refer to the appropriate policy sub-sections listed below for specific billing procedures.
1. USHAI 360a – Billing Insurance
2. USHAI 360b – Adult Patient and Patient’s Spouse Assessment - Procedures
1. 835 Posting Report (Medicare Explanation of Benefits (EOB)): A report the USH sends to ORS. This report shows Medicare payments that have been paid to the USH.
2. Bed History Report: A report generated by the Utah State Hospital (USH) and sent to ORS once a month. This report shows how many days a patient has stayed at the USH. ORS uses this report for charging the insurance company.
3. Daily Rate: The total cost per day to stay at the USH. The USH notifies team 78 when the daily rate changes. Team 78 keeps an updated list of charges.
4. Insurance Cases Being Billed List: List of insurance cases that ORS has billed for the month. This list is updated every month and sent to the USH.
5. Medicaid Coverage: Provides health insurance coverage for qualified people who are unable to afford it.
6. Medicare Coverage: Federal health insurance program for people age 65 and older and for certain disabled people. Medicare will pay for many of the health care expenses and will pay for 100% of the first 60 days of care at the USH, if not used prior to the USH admit.
a. Auto Crossover carrier: an automatic method of transferring Medicare claim information to insurance companies that offer policies which supplement Medicare coverage.
b. Supplemental Carrier: a supplemental health insurance plan offered by the beneficiary or beneficiary's spouse's former employer to supplement Medicare coverage. This is not an automatic method and requires ORS to bill carrier.
7. Primary Insurance Carrier: Insurance that pays compensation for a loss ahead of any other insurance coverage the policyholder may have.
8. Secondary Insurance Carrier: Insurance that pays compensation for a loss after the Primary Insurance Carrier is billed.
1. H50A – F.R.A.A. First Request: A notice sent to the patient and the patient’s spouse notifying them of their legal responsibility to pay for all or a portion of the USH costs, based on their ability to pay. This form is sent with the “Patient/Spouse Income Asset Information sheet” (form SHAI), which requests information to assist ORS in determining the ability to pay.
2. SHAI – Patient and/or Spouse Income/Asset Information: This form requests asset and income information from both the patient and patient’s spouse (if applicable). Send this form with the H50a letter to both the patient and patient’s spouse.
3. SHIA – ORS/USH Patient Medicaid, Asset & Income Assessment Worksheet: Use this form to assess the patient and patient’s spouse an obligation. Complete this worksheet using the information found in the SHAI form (see #3 above).
4. HVPA – Voluntary Payment Agreement: Send this agreement letter to both the patient and patient’s spouse (if applicable) by certified mail. This letter states the amount the patient and spouse owe towards the USH costs. Both the patient and patient’s spouse, if applicable, must sign this form.
5. XATY – Attorney General Referral: Complete this form prior to referring a case to the Attorney Generals Office (AGO). This form includes patient information, spouse information, and case details
6. Y62A - UB92 Insurance Billing Statement (Insurance Claim): Send this form to the patient’s insurance company. This form shows the time-periods and dollar amount the USH is charging for the patient’s care. This form must be manually generated.
Coordination of Assessed Payments with Insurance Payments
Third party (insurance) coverage for a patient does not relieve any responsible party of their assessed responsibility, unless the third party pays in full the complete cost of the patient's care at the USH. Insurance payments may offset the patient's and/or the patient’s spouses assessed obligation; however, do not assume that insurance payments will cover the responsible parties' assessed obligations, since insurance payments may not be realized until several months after the assessed payments are required. However, if insurance payments combined with the obligor(s)' payments, result in the USH being overpaid for the cost of care, the USH will refund the overpaid amount to the private parties (patient/patient’s spouse) at the time of discharge.