1. A. Billing Limitations.

   1. 1. Except as otherwise provided by a specific provision of the Workers' Compensation Act or this rule, an injured worker may not be billed for the cost of medical care necessary to treat workplace injuries.
   2. 2. A health care provider may not submit a bill for medical care of an injured worker to both the employer and the insurance carrier.

2. B. Discounting and down-coding.

   1. 1. Discounting or reducing the fees established by this rule is permitted only pursuant to a specific written contract between the medical provider and payor or guarantor, or an agent of the payor or guarantor, through a bona fide provider network arrangement, and is disclosed to the provider. A third party administrator or claims processing agency may not apply a discount absent a specific written contract with the provider.

   2. 2. A payor may change the CPT code submitted by a health care provider under the following circumstances:

      1. a. The submitted code is incorrect;
      2. b. Another code more closely identifies the medical care;
      3. c. The medical provider has not submitted the documentation necessary to support the code; or
      4. d. The medical care is part of a larger procedure and included in the fee for that procedure.
   3. 3. If a payor changes a code number, the payor shall explain the reason for the change and provide the name and phone number of the payor's claims processor to the medical provider to allow further discussion.

3. C. Place of Treatment. A medical provider's billing for a medical procedure must identify the setting where a procedure was performed.

   1. 1. In an office or clinic: Fees for procedures performed in an office or clinic are to be computed using the Non-Facility Total RVU.
   2. 2. In a facility setting: Fees for physician services for procedures performed in a facility are to be computed using the "Facility Total RVU," as the facility will be billing for the direct and indirect costs related to the service.
4. D. Separate Bills. Separate bills must be presented by each medical provider within one year of the date of service on a HCFA 1500 billing form. All bills must contain the federal ID number of the provider submitting the bill.

5. E. Hospital Fees.

   1. 1. Fees covering hospital care shall be separate from those for professional services and shall not extend beyond the necessary hospital care.
   2. 2. All billings must be submitted on a UB92 form, properly itemized and coded, and shall include all documentation, including discharge summary, necessary to support the billing. No separate fee may be charged for billing or documentation of hospital services.
   3. 3. Fees charged by health care providers for services performed in a hospital are subject to the Commission's fee rules.

6. F. Charges for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies, Materials, or Drugs.

   1. 1. Ordinary supplies, materials or drugs used in treatment shall not be charged separately but shall be included in the amount allowed for the underlying medical care.
   2. 2. Special or unusual durable medical equipment, prosthetics, orthotics, and supplies, materials, or drugs not included as a normal and usual part of the service or procedure shall be paid at Medicare rates if available and if not then at cost plus 15% restocking fees and any taxes paid. Discounts shall not apply.

7. G. Miscellaneous.

   1. 1. A physician may bill the new patient E and M code when seeing an established patient for a new work injury.
   2. 2. Payment for hospital care is limited to the bed rate for semi-private room unless a private room is medically necessary.
   3. 3. Non-facility RVS total unit values apply, except that procedures provided in a facility setting shall be reimbursed at the facility total unit value and the facility may bill a separate facility charge.
   4. 4. Items that are a portion of an overall procedure are NOT to be itemized or billed separately.
   5. 5. Payors may round charges to the nearest dollar. If this is done on some charges, it must be done with all charges.

8. H. Prompt Payment and Interest.

   1. 1. All bills for medical care of injured workers must be paid within 45 days of submission to the payor unless the bill or some portion of the bill is in dispute. Any portion of the bill not in dispute remains payable within 45 days of billing.
   2. 2. As required by Section 34A-2-420 of the Utah Workers' Compensation Act, any award for medical care made by the Commission shall include interest at 8% per annum from the date of billing for such medical care.

9. I. Billing Disputes. Payors and health care providers shall use the following procedures to resolve billing disputes.

   1. 1. The provider shall submit a bill for services with supporting documentation to the payor within one year of the date of service.
   2. 2. The payor shall evaluate the bill and pay the appropriate fee as established by this rule.
   3. 3. If the provider believes the payor has improperly computed the fee, the provider may submit a written request for reevaluation to the payor. The request shall describe the specific areas of disagreement and include all appropriate documentation. Any such request for re-evaluation must be submitted to the payor within one year of the date of the original payment.
   4. 4. Within 30 days of receipt of the request for re-evaluation, the payor shall either pay the additional fee due the provider or respond with a specific written explanation of the basis for its denial of additional fees. The payor shall maintain proof of transmittal of its response.
   5. 5. A payor seeking reimbursement from a provider for overpayment of a bill shall, within one year of the overpayment, submit to the provider a written request for repayment that explains the basis for request. Within 90 days of receipt of the request, the provider shall either make appropriate repayment or respond with a specific written denial of the request.
   6. 6. If the provider and payor continue to disagree regarding the proper fee, either party may request informal review of the matter by the Division. Any party may also file a request for hearing on the dispute with the Adjudication Division.

KEY: workers' compensation, fees, medical practitioners, nurse practitioners

Date of Last Change: January 1, 2026

Notice of Continuation: September 26, 2022

Authorizing, and Implemented or Interpreted Law: 34A-1-104; 34A-2-201